Laparoscopic Pediatric Hernia Repair 2025

Good morning. Good afternoon, good evening. Uh, we're so excited to do this hernia course again. We appreciate everyone joining from all over the world. Um, it's exciting to me to see that, uh, even by doing this every year, uh, there's still people interested in learning about hernias, um, and this laparoscopic approach. Um, we, uh, for those of you who have, uh, attended some of these events before, especially the hernia event, this is guided with uh a presentation, but really is effective when people just ask questions and give your thoughts and comments. Uh, feel free to uh engage me, disagree with me, tell me, uh, better ways of doing it. I think I learned more than everyone else on this from other suggestions that people are doing and trying. Um, oftentimes, a lot of the same questions get asked, so I'll try my best to predict those and answer those. Um, but, uh, let's, let's jump in. I think, first of all, I just wanna thank, um, All the people that uh contributed, we try to offer these events at no cost, and, uh, of course, no one ever needs to, to donate anything, but, but it's very much appreciated, uh, the contributions that, that you've made. Um, moving on, if there is a technical glitch, um, which for those of you who've been following these events for the past 12 years, uh, we used to have it almost every single time. Thankfully, the technology is getting better. Uh, but if it happens, usually just refresh your browser, we'll try to send notifications if there's an issue, and this is recorded, and, uh, we can get you the, the recording, um, if you need it. Um, feel free to email me any questions. Um, we can, uh, put my email in the chat. Um, it's, uh, Todd. Ponski@ CCHMC.org. Um, and, uh, uh, would love to, to, to dive in. So if there's not any, um, Questions or issues, and I, I, I wanna thank um Cincinnati Children's as well for, for helping with this. So, um, let's get going and um We will go right to. Presentation. So, before we start into the lab stuff, I wanna start with some of the most um uh common questions or uh that, that people bring up about uh hernias in general, uh, not even just the laparoscopic. So, um, you know, this is the bread and butter thing we do. That's, uh, I don't know if that phrase translates everywhere, but it's the, it's the essence of pediatric surgery. It's what we do every day. And uh it's surprising that there would still be any, um, any debates or dilemmas, because everyone thinks, you know, I do it the best. So, um, you know, this is my way, there's no better way. Uh, and, and so, but yet, there's still a lot of, um, of questions about it. So, um, let, let's start with this one. An 8 year old boy with a, a good history of a groin bulge that comes and goes. By what the pediatrician says. They say it comes and goes, mom says it comes and goes, and they come to your office, and you don't feel a hernia on exam. And in kids, this is much more often than adults. So I'm just curious, there's no right answer here. How do people approach a story of a hernia without actually a hernia, um, on exam? Do you do a groin exploration? Uh, do you, uh, do laparoscopy? Do you wait for a photograph, um, or do you only operate with physical findings? Um, so, let's see what we got here. So Isla or uh Carolyn, because I am blind, you're gonna have to tell me the, the results here. Looks like, All right, I think, let's see, I think I, I figured, so, yeah, I, I think here it's all over the place, which looks like a rainbow, which means uh people are still all over the place. So I would say maybe the most common is that people would go to laparoscopy, um. And, uh, a lot would wait for a photograph. So, um, here is sort of my, my thoughts on this, and again, this is, uh, I'm, I'm, I'm not any more expert than, than anyone else, just one person's opinion. I don't do a groin exploration. Um, I don't put the groin at risk just, um, uh, from a story, um, without seeing anything. I would do laparoscopy. I think that if you have a good story, that something comes and goes, and The only thing that it could be that, that is not a hernia is that maybe it's, it's a, uh, a mobile testicle that, that comes and goes, and it's, um, as long as they feel it when it's down there and, and it's, they can feel the testicle separate from the actual bulge. Um, other than that, it's almost always a hernia, and the success rate that I've had on looking with a really good trusted story, um, is pretty high. However, lately, I've really moved from even doing nothing. And that's because of studies that we've done and others to show that if the child is old enough, after 1 year of age or 2 years of age, especially, The chance of incarceration is very, very low. Um, and so, telling the, the parents to just, you know, take a picture, um, or wait and see if it keeps happening, you're probably OK. So, um, I wouldn't do a personally, but I would do either a laparoscopy, um, or maybe wait for a photograph, but, um, I don't need physical findings, um, to do it. Um, and I leave it up to the parents. So I don't know, um, if there's any discussion or comments on that, so I will keep going. Um, all right. Another, another question. You're doing a lap Api and you see a patent prosthesis vaginalis. What do you do when you find that? Do you do a hernia repair at the time, a lap hernia repair, or an open hernia repair? Do you scrub out and go talk to the family? Do you just do the appendectomy and tell the parents about it, but tell them that there's an increased risk for hernia, but not do anything, or do you plan For a delayed hernia repair. So you say we're not gonna do anything now, uh, but we should do a hernia repair at another time. Let's see what people do here. Um So It looks like Most people would close and tell the family that, yes, there's an increased risk, but we don't need to do anything. Oh, that just shut down. Let's see. Um, it looks like, um, it's all over the place now. Um, It's so funny, it's all over the place. So, I, um, personally would never fix the hernia at the time of an appendicitis just because it's an infected field. That People could argue against that and say, as long as it's not perforated, um, then, um, it's, it's probably fine. Um, but I just don't do it, plus you didn't even ever have the conversation with the parents about What it is all about with the hernia repair. So, I don't do it at the time. The question is, would I do uh D or E? Um, I give it a choice to the family. I pretty much do D. I just tell them there's an increased risk for a hernia. And if they ever see a hernia, let me know. But because we know that incarceration is so low in this age group, um, they could just wait to see if there's an issue, and that's pretty much what I do now. I don't schedule them unless they ask for it, which is totally reasonable, and then I'll fix it. Again, um, Uh, let me know if anyone has any questions, uh, or comments. So Isa, let me know if there's thoughts on this. Um, contralateral evaluation, if you do it open. Um, do you put a scope in, or do you even look at the other side, um, open wise? So, Um, there's a high chance of there being a patent prosthesis on the other side. Um, and physical exam is not reliable for PPV all the time, and they have a high chance of hernia. Um, so some could argue to go fix it and to look at the other side. Um, And there is about a 3 to 11% chance that they'll get a hernia on the other side, um, at some point. And then you don't have to go through a second operation. So, uh, a lot of people argue for, if you've consented someone for a hernia, they know all about the hernia, you've had the conversation with the parents ahead of time. A lot can argue for fixing the other side. Um, arguments against doing it is just because there's a patent prosthesis does not mean there's a hernia. And by the way, I've now seen 3 studies showing that PPVs can close, um, over time. That, uh, so, it doesn't even mean it will be there forever, theoretically. Um, half the time, you'll fix the PPV and they never needed anything done because they would have never gotten a hernia. Um, you could cause injury. Um, you could cause testicular injury, um, with, or atrophy, um, you could have infertility. There's risks of exploring the groin depending on how you do it. Um, and that, so what, you bring them back a second time is not a big deal. And there's a low risk for incarceration. So, I'm hedging again that there's really no correct answer. Um, what I do, um, is If I'm doing it lap, um, I will. Talk to the parents about what do I find if I find something on the other side. I ask them if they have a preference. If not, I tell them if it's, if it's something there, I usually will fix it. If they have any preference, I will absolutely leave it alone. I have no problem with that. But, um, I lean towards fixing it. Again, there's no right or wrong answer, that's just me and my practice. Um. Timing of operation for a pre-term infant. So, um, in a preemie that's in the neonatal intensive care unit, do you fix it before they go home, or do you fix it, um, you know, later on when they're older. There's studies that keep coming out, I think we reviewed one this year that show benefits. I've seen both studies, Better to wait, better to repair it. Um, I think I base it on the parents, again, and the The health of the child, and do I trust that the parents will be able to um manage that at home? Do they live far away? Those are the types of things I consider. Um, and if I'm concerned in any way, I'll fix it just before they go home when I'm sure that they're perfectly um healthy. All right. Now, this is gonna launch into the rest of the, the time here about Um, how do you manage? An inguinal hernia. Um, so, um, So Let's see. So you have a six year old, I'm sorry, I'm reading some of the comments. A six-year-old with a reducible left inguinal hernia. Um, this is your classic hernia. Um, how do you fix a classic hernia? So, uncomplicated six year old, you felt it on exam, you do an open repair. Do you put a laparoscope in to confirm, and if it is a hernia, then you fix it open. Do you do an open repair and laparoscopically look on the other side? Do you do a laparoscopic repair intracorporeally? So you use at least 3 incisions and you, you fix it with 2 instruments in hand, in uh intracorporeally, or do you use needles and do a laparoscopic repair that way. Always curious how this goes, especially as um time has passed over the the years. So, It looks like Uh, it is split between split between open and perk lap. Um, which I'm not at all surprised about, um. So what's great is how many are doing lap. And still coming to to talk with other people like this, because I'm the same, I Always want to hear new ways of doing things, even if I'm already doing it. So, um, We'll look at that. And again, if anyone has comments to defend what they do, um, Uh, and, and I'm gonna make a, a big comment right now, just, just put it out there. Um, there is no right answer here. If you're expecting me to, uh, tell you why you have to do lap hernias, I'm not gonna say that. I will tell you that the open repair. is very good in someone who's very good at it. The results are good in someone who just does it a lot, does it well. It's great The lap repair is really good in someone who does a lot of it. So do what you're comfortable with. These are, it's just suggesting another way of approaching it. I'll explain why I've switched to the lap repair, but it is not better, it is just another way of doing it, and um I will uh I will be happy to hear all the different opinions on that. Um. So let's talk about the open repair. It's the most basic operation we've been taught in, in pediatric surgery. It's pretty straightforward. You do a high ligation. Um, by the way, not everyone does a high ligation. Some people do just division of the sac and without ligation, which seems to work, which supports another thing we'll talk about later. It just shows that scar itself is what works, not actually tying off the sac. But let's talk about laparoscopy. So, I think, here's the argument for the open repair. This is what I would say if I were to defend the open repair. It works. It's worked for many, many years. Why mess with good? It works. We have really good outcomes with an open hernia repair. Why would you mess with the, the thing we really know how to do? It doesn't recur very often, it, it, um, very low complication rates. There's Pretty much no visible scars except under the underwear line, so it's not cosmetically a problem. In the laparoscopic repair, you're still. For the, for, for many of us still leaving the sack. Some do remove the sack, but for most of us, we don't. So theoretically you're leaving the sack there, and people would say, just get rid of it, you know, do the open repair. In the lap repair, it may need to rely on a stitch forever. That gives a lot of people pause, that I'm doing an operation, I have to put a stitch in, and please stitch work forever because uh I hope this lasts for the patient's entire life. So, that is an argument for open repair, um, which, uh, we'll talk about. Um. And the laparoscopic repair takes an extraperitoneal operation and makes it intraperitoneal. Why would you go in the belly if you don't need to? So I think I'm making a good case for why people would just do open. It's what they've been taught, they have good outcomes, and all of these other things. If I left anything out, please put it in the comments. All right, now we're gonna talk about why some may do the laparoscopic repair. Some say We pat ourselves on the back about how we do an open hernia repair. And we don't see the patients again except for one follow-up visit, maybe. But there's things we don't know about what happens during that operation. That may have a lasting impact. There have been many studies in rabbits just by taking the vase of a rabbit and, and, and grabbing it with the pickups, that uh it's been shown to um Let's see if we have questions. Um, it's been shown to, uh, Cause obliteration of the vase. So when we're in there, separating the sack and, and, and retracting away the cord, this whole operation, we're pulling the cord and we're separating the sack. Even if you're gentle There is a chance that you are causing on this tiny little structure that is barely patent at that age. Any type of scar will have a lasting impact. So we don't know the long-term impact of, of messing with something so fragile at such a young age. So some people like the fact that in the lap repair, you don't touch the cord. You leave it alone. There's some benefit to that. Maybe, maybe not. A lot of this is theoretical. Um. Uh, So, there's a, there's a lot of questions we'll get to um in a bit. So, um, What about cosmesis? You know, a lot of the benefits of laparoscopy are that you have less scars. Not here. I would argue that yes, the scars are smaller in laparoscopy, but they're visible. They're above the underwear line, whereas in open, it's below the underwear line. So I'm not sure anyone can argue that lap hernias are better cosmetically. Then open. So, uh, I, I don't buy that one, Uh, yes, um. Yeah, sorry, I will remove myself. I think someone asked, can I remove myself? So let's do that. Here we go. No more Todd. Um, so, And then What about What about pain? So this I, I think is an issue. So, not everybody has pain, but Especially in adolescences, or as they get older, and you're doing an open hernia repair in one of the most neural neurally dense areas in the body. It hurts. And there's a risk of nerve entrapment, nerve injury, especially in a, in an inflamed groin. So, I think that pain is an issue that laparoscopy is substantially better at, that post-operative pain, they shouldn't really need much at all. Um, and we'll talk about that in a bit. What about infertility? Ben Zendejas did a study when he was a resident at the Mayo Clinic where they did fifty-year follow-up. 213 patients, 5% were infertile. I'm not sure that's any different than the general population, maybe more. Um, there's been other studies that suggest that there is, um, semen, uh, disruption in patients that have had open hernia repairs. Uh, I'm not sure I buy it. I don't know if that's really an issue. I'm curious if others have a different opinion. Um, and Isa or Kiki, just, just let me know if you want me to, um, hit on a question that's more pressing. Um. I could do this right now. Let me finish this, and then we'll get to these questions. Um. And, all right, everyone, so, those who've seen this before, know this is my favorite part. This is the reason that I do lap hernia repairs, this picture. This is why I do it. So. If you are on a boat in the middle of the ocean. And It is beautifully sunny outside. And The water looks like this on the surface. What does the water look like under the ocean? It's beautifully calm. Pristine. What about a day like this, where If you are If it's a storm, and there's waves crashing on the surface of the ocean, what does the ocean look like deep underneath? The same. Still calm. That's why I like the lap repair. This is a calm ocean on the outside, calm ocean. And this is what it looks like inside. Always calm. This is what I would consider not a calm ocean. This is a tempest. This is a storm on the outside. Very treacherous to go in there in a baby with a very tiny vase and think that you're not gonna have any chance of causing a floor injury, a vase injury, a uh atrophy atrophy of the testicle by disrupting. There's so many things that you could do in such an inflamed area. But under the ocean, it looks like this. So no matter how bad it is on the outside, the inside is always calm. That's why I like the lap hernia repair. That if you get used to it, and get, you get good at doing the lap hernia repair. On the tough cases, you'll be able to do it with no sweat dripping down your face, because it is just as easy as the easy cases. That's why I do it. I think overall, we're gonna have better outcomes. So, When we look at, what about incarceration. So, uh, before I get to incarceration, let me take a minute to answer some of these questions. So, Um, all right. Um, so, I saw that Gabriel's, uh, when we were talking about appendicitis, that depends on the severity. I'm, uh, that's a great question. I, I, I hear you. Um, I just, and then I would say, I would say if you're gonna fix it, and you would say that the appendicitis is mild and you believe that a PPV should always be fixed, I would just say go talk to the parents. Because they might say, why did you fix that? I never told, gave you permission. So, I, I wouldn't, because I think we're finding that leaving them alone is not a problem, but I don't think it's wrong, as long as you have a conversation. Um. And, uh, And then find ways, yeah. Um, I, I, I maybe Islam, if you could explain, first to find what is a gold standard, and then find ways to achieve it. Um, I think I love that phrase, but I wanna make sure I understand it, so maybe explain it to me another way. Um, I think I'm gonna like that quote. Um, can you manage the airway without an endotracheal tube? Yes. Um, I should add that to that talk. Isa, remind me to add this to the talk. The group, um, uh, Akron Children's, and I think others, and please comment if you've done it, can now do this under deep sedation without endotracheal tube. They, they have a series they've done with great results, both lap and open. Um, so, yes, you do not need intubation, although I still do it cause I'm a wimp, uh, and I'm getting old, but I, people are doing that and I could be convinced to do that too. Um, How do you evaluate persistent inguinal pain at the needle sites in the groin? OK. There's, let's get to that, I guess, do I do that now or later? So, that is a very complex question. If you have pain after a lap hernia repair, Um, it is really troublesome. It has. Definitely happened. That is a great point because I have not had recurrences that I've operated on, but that I have had. People that have discomfort and If it, if after trying, you know, time and, and nothing makes it better, you can go in and cut the stitch out because um I have cut out stitches before for granulation tissue, for granulomas where the stitch gets rejected, and I've not had a recurrence because you'll see why later. I think it's scars in and I've, I have to talk to, I have a colleague that had that happen and I have to see what happened when they cut the stitch out. Um, it's very rare. And I think if you use the technique I'm gonna show, um, having pain is extraordinarily rare, um. Uh All right. Now, I'm, I'll, I'm gonna put myself back on camera cause I see, uh, have, have both. So, uh, there we go. Um, I'll go on and off so we can satisfy everyone. Um, the, uh, The, the hernia repair potentially can cause pain due to possible broad ligation of the area. Totally agree. I'm gonna get to that. That is why I switched my technique. When I first started, it caused pain cause I grabbed too much stuff. Petkowski Takahara's technique that I use now, grabs almost nothing, and that's when I have almost no pain. Um, and I think, I, I, I will promise you those who know me well. I will not in any way exaggerate my outcomes. I, I am the most uh honest with like, when I screw up all the time, I'm being totally honest that I have so, almost no cases of people that like rare, maybe a handful of people that have said I had discomfort. I've, I've not had to remove a stitch yet for that cause it usually goes away. I also haven't had recurrences that I know about. I'm sure I have. They probably went to another surgeon, uh, someone better, smarter, stronger, faster than me, but I haven't had, I haven't seen them. I have had others that I know have had recurrences, but I, for some reason, Haven't had to ever re-operate, except after my first case when I did this other technique. When I switched, I haven't had anyone come back to me. So that's the only statistic I can give. I have never had to re-operate. On a recurrence after this technique. I'm sure I've had recurrences, but I haven't re-operated, um. So, let's see what else. Um, Uh, da da da da da da, um. The um cost probably is less for open. You know what? I don't know how I have not studied that. I'm sure others have. Isa, can you remind me to look into that? Does anyone know if there's studies comparing cost of open or lap? Um, you might be right. The cost might be, I think it depends on your hospital, um, because we do everything laparoscopic. I don't think. Um, it, but it's a great question. It, it might be more expensive, um. It is like an ocean inside also after an irreducible hernia. Um, I'm gonna show that. I'm gonna show it. Yes, it looks like an ocean, but it's not a bad ocean. It's inflamed, but that actually, I think makes it easier cause the edema makes it nice and easy. So you're, it's a great point that an incarcerated hernia, it doesn't look pristine like this picture. It's swollen, but it's still easy to do. So, it's a lot easier than on the surface. That's a good point. Um And uh, And let's see. So, what about a baby with a history of surgical neck? Great question. If you think it's gonna be an ugly abdomen, If you think it's treacherous, and you're even afraid to put a laparoscope in, do it open. Um, if I feel like I can like lift the skin and I can get access, I'll look with the laparoscope. But if there's a, a, a concerning hostile abdomen from the past, just do it open. That's why it's good to do both. By the way, if you do lap, You should do groin explorations, either do occasional open hernias or do um undescended testicles, orchidopexy. You've gotta still stay comfortable with the groin. And that's a risk of this, is if you don't do it for many years, you're not gonna be as comfortable. So I think it's totally fine to do open. Um, when needed, um. So, Osama asked about, are we missing data on injury for laparoscopy because it's a newer technique? Yes and no. Um, there have been studies looking at um, Surrogates for injury, which would be testicular atrophy. And there's a lower rate from what I believe, I think this was Felix Shear. Again, I might be lying about this, so I have to check. So Isa, remind me this. One of the recent studies looking at um Uh, surrogates for groin injury in laparoscopy. Namely, is there a risk of suturing in the vase or the, the vessels? Great question. Until we have long-term data, we won't know. So, we have talked about ways of testing this, which you can't do, which is asking the kids to get a Siemens. You'd have to wait till they're adults. So, we're starting to get long enough into this that we might be able to look at that and I think um we could ask people that are much better at doing these types of studies than me is to really look at long-term outcomes of vas or vessel injury. It's a great, these are great questions. Um We frequently do underspinal for both lap and open. No airway support at all. So, Tim, uh, would love to hear your thoughts on that. Um, I know we can't have people call in. Uh, maybe you can even call my cellphone and we could have you call me. We'll, uh, text if you wanna do that, we could try to figure out a way where you can call in and tell us how, how you're having experience with this. Um, So, uh, here, oh, right, people, let's see, I'll go to, uh, here, just. Just me. Um, What is the turning point to decide for open repair instead of percutaneous? Um, we're gonna get to that. So, that's coming up. Unlike many other procedures where lap versus open are somewhat analogous operations, lap versus open hernia are completely different. How important is to maintain skill set? See, Mindy, I answered that. So, great question. Totally agree. Um, I would say that's what I did wrong, to be honest. I got so comfortable with the lap that I didn't, only time I do groin operations is for a rare hostile abdomen or for orchidopexy. I wish, maybe like I did more opens just to make sure I stay comfortable with the groin. The other thing is, if you do laps for your whole career, um, I mean, we, this is a whole conversation. Do you get one of your partners to, to, to come in who does them open. I don't know, that's a wimpy answer, um, but it is something very real to think about. Uh, um, how do we stay comfortable in the groin. Um. Um, we should talk to Nigel. So I'll email uh Nigel or someone can email him and tell him to join and ask us about what he found in costs. Um, is there any study about abdominal adhesions post lap hernia repair? I have not seen anyone report that. Um, I have not had or heard of anyone having a small bowel obstruction. Or any complication from adhesions, but again, to that other point, maybe it's too soon. Um, maybe we will see adhesions. Um, again, your hands aren't touching anything, so it's just your instruments, but you, I doubt there's a lot. If anything, it's adhesions right at the internal ring, which you would have with open as well. Cause when you do the cut in the ligate, it drops back into the abdomen, so you have the same scar there that you would for lap. But Uh, I'm gonna answer all of these questions by saying, these are valid points that we don't have the answers to. So, um, if you're waiting for the data, you might have to wait another 10 to 20 years. Um, all right. I think we can do a couple more. The debate between open and lap should not end with what's best in one surgeon's hand is the best for the patient. Oh, I wanna hear this. OK. Well, this is abs this is absolutely true, I think you meant, and will always be true. Research should focus on comparing two standardized techniques to randomized control trials to conclude which is best, then devise ways to achieve it. Case in point, first introduction of lap coli. Wow, that's like a whole. That is such a great question that you don't like the answer of what's better in your hands. Let's debate that. We should have that at the update course because what about access? Like, some people say, do you do a Vus or Hassan, and they say, do what you're comfortable with. Even like, what if there is no better? Is there always a better answer? Um, Islam, I love that question. Can you email me? I would love to have you talk about this. We should debate this, cause, um, I would love to hear other people's thoughts on that. I think you're right. It might be a cop-out, but sometimes there are just two ways of doing things, and one is not better. I'm not sure there's always a better way. Um, Todd, I've seen, so Jose says, Todd, I've seen babies with huge hernias that I go in laparoscopically and the ocean is not so calm as you say. Um, they have a huge inguinal ring and huge redundant sac. Those cases recurred with a purse. Fair enough. I would say. Maybe I, I have to stop being so dramatic and saying it's always easier. It's generally easier. Um, maybe you're right, it's not always, but I have videos that I'll show you what it looks like inside. Um, I still think it's easier than outside. I still would rather be under the ocean than above the ocean, but Again, if your lap, and it's hard, go open. I mean, there's almost no downside, so it's just to see which, which is better, the outside of the ocean or under the ocean, and, and you could pick. Um. By the way, this is the most fun hernia course I've done so far cause there's so much conversation. Uh, for post-op pain, which is rare, we have used What, oh, the ileolinginal nerve block and steroids. Never had to remove the stitch yet. Totally agree, Mindy. Happy to have you call in about that. Um, would love to hear people's tips and tricks on how they've managed the pain. Um, I like, if there's no way for them to call in, like if we can make a Zoom link. If not, they can call my cell phone, and I could just put my cell phone near the computer. Um, so Mindy, um, we can put, um, My number in the chat and then um just text me if you wanna call in. We'd love to hear your thoughts on this. Um. A presentation in the present iPE case report of post-op adhesions. Oh wow. Gabriel, do you know who presented that? If you could let me know, we'll contact them. We'd love to know if it was a case report. I'm, I'm not gonna change my practice on that, but it's a data point. Um, but I think you get adhesions even from open repairs. So, uh, it's that scar, um. At the orifice, um. All right. Last text and then we're gonna go on. Writing for a group of us logging in together, um, for long-term recurrences, probably dealt with by the adult surgeons. Yes. Any insight into what is more challenging to deal with someone with a history of lap open repair. We will get to that. Um, I worked with my adult colleagues, we need to have them tell us. Um, How would you do redo a hernia after open? We're gonna talk about it. I always will do lap, cause that's, I always do lap after recurrence. Whether it was done lap or open because I wanna see what's causing it. I think you'll get a better idea of lap. Um, but uh it's theoretical, I haven't had to do it yet. Um, actually, there was a bulge that I, uh, so, I had a kid that had a bulge after I did a lap hernia repair, went in laparoscopic and there was no recurrence. It was a lipoma. Um, so that was just me being an idiot. Um, how would you do a red hernia? OK. I think the president IPE did not describe it clearly. We should find out. All right. Sorry for the questions. Now we're gonna get back to, um, this, and then I will, for the slides, I'll remove myself here. So, If I'm covering it up, I'll move myself. So, um, here's an incarceration. So, I have a question here, I'll I'll remove myself. Um. So, I'm gonna make a pro, this is the best group I think we've ever had, cause you're fighting back against me, which I love, cause um this is great. All right. What I was taught with open hernias is that you get a call, there's an incarceration in the emergency room, you go down, you reduce it. And you admit them, and you do the hernia the next day, or you send them home and you do it the next day. And the reason for that. Is because of the inflammation. Now, a lot of you are pushing back on me, so we'll get to that. So, um, I, I think this course would be much better if we do it by Zoom next time where everyone can chat. Anyways, um, What if you can reduce it in the emergency room? So, I don't know if we have a poll on this, probably not, but put your comments in. If you can reduce it, yeah, sorry to interrupt, it's Isa. Um, I just want everyone to know that you are able to join us. I'm putting a link in the chat, and if you'd like to be on stage with Todd, click that link, and I'll let you in. Thank you. Yes, and we would love, like people that I've called out that like Mindy or others who have experience, I forgot who did the spinal, um, like anyone who's done stuff, like call in. We'd love to hear, um, what you guys have done, um. So, what, what do you do if you can reduce it? So, I'm assuming most of you do what I described, um, And what if you can't reduce it? What do you do if you push and you can't reduce it? That some would say you can always reduce it, but if you can't. So, I've changed my practice. So what I do now is I will, if I get a call, and they say that there's an incarcerated hernia, now, you guys are gonna laugh at me, so I'm gonna put my face up here, so I, I take the heat from you. If I get called about an incarcerated hernia during the daytime. Uh, 2 o'clock in the afternoon, incarcerated hernia comes in, oh man, you guys are gonna throw tomatoes at me that I'm practicing different based on the time of day. But if I get a daytime call that there's an incarcerated hernia, I will tell the resident, don't even try to reduce it. There's no point. Don't put the baby through the pain of squishing on the groin, just leave them alone. Let's take them up to the operating room and put a laparoscope in. We'll reduce it under anesthesia, and we'll fix it. The whole thing of waiting. Isn't as necessary with laparoscopy. Now, some of you disagree with that, which is totally fine. But I have no problem going in on an incarceration, push it back in, it's edematous. But I have not found that to be that hard. And it avoids the pain and suffering of the kid by pushing there, even if I sedate them. This is what I do, and I, I could be pushed either way. I don't think I'm right here, this is just what I do. Or if I cannot reduce it, I take them to the operating room and I put a laparoscope in. Now, this is a video of um me doing this now. Um, what you're not seeing is that I'm pushing on the outside. So one person squishing, this is under anesthesia, squishing it from the outside, while I'm gently, like into susception, barely pulling, you don't wanna tear the bowel. So just a little bit of counter traction while I'm pushing, and squeezing and pushing, and slight bit of counter traction, you don't even have to probably do that, just to sort of pull it a little bit out of the way, and it takes time. And you just gently push, and you're pushing, and then you get to look at the bowel and see if it's messed up, if it's like damaged or bruised or ischemic, or perforated, God forbid. There it is. OK, so, this is what it looks like after incarceration. It is edematous. But I like the edema, because this takes the place of me. Uh, injecting, uh, hydro dissecting it auto hydro dissects. So then I can just go ahead and do, uh, the, the hernia repair, um, and yeah, sorry to interrupt again, it's me. Um, I think you're supposed to be sharing your slides and, oh my God, I'm such an idiot. All right, sorry guys, uh, and also, um, Victor Andrade, I hope I'm pronouncing that correct, um, has joined us in stream yards. So just so you know, all right, Victor, this is awesome. Let me show this again cause I'm an, I'm an idiot, um. So Uh, sorry. So, This is the incarcerated video. So pushing from the outside. And just gentle traction on the inside. And then you'll see in a minute, that's what the ring looks like, which is edematis, but that actually helps me see my needle, it pushes the vase away, and I can see my needle under. Um, I wish I had for this video, um, me passing the needle to show you what it looks like. Victor, what's up, man? Is he there? Yes, but I think he's muted. um. Oh, Victor Victor, Uh, no, no. All right, all right. If we get it working, let me know. OK. All right, sounds good. So, um, let's keep going now. So What about, so the main argument for lap repair, this is another one. I always keep saying the main. Here's another argument for lap repair. This was a case that I operated on about 10 years ago. Um, at the county hospital, and I, it was a recurrence. So this was the question you asked, how do I manage recurrence? This was an open hernia repair from a really good surgeon. Trust me, this is like a really good surgeon. Open hernia repair. And from out of, it was from another uh city, sent to us, and it was, uh, I go in and I see that, in fact, The repair was intact. This was the indirect inguinal hernia. They now have a direct. As a child. Now, here's the thing. Why did this happen? Is it just that, when someone gets a direct hernia after an indirect repair, is it because they were gonna get it anyways, or did we cause it? Because we are damaging the floor when we're doing pediatric open hernia repairs. I don't have an answer to that. You, people who have been texting about smart studies, there's gotta be a way to figure this out. But let me show you what studies are there. Ben's paper, the fifty-year follow-up. They and Jay's, Jay Grossfeld's paper, um, that most recurrences after an open indirect hernia repair are direct. Our medial hernias, are, are, are floor problems, are muscle problems, not recurrence of the high ligation. The high ligation doesn't recur, it's that they have a direct hernia. So, is that just because they developed a new type of hernia? Is it because we misdiagnosed the first time and we did the wrong operation? Or is it that we caused it? I'm so curious what people say in the text, um, So, um, And, hey, Isa, next time we do this, you're right. I do need someone doing this with me because if there's relevant questions to what I'm actually saying, at that time, you can interrupt me. Um, so, uh, um, we can do that. Anyone's welcome to join and be my co-host now. Um, anyways, so, I think we are damaging the floor more often than we know. So basically, let me say this again. The most common recurrence after an open indirect high ligation is a direct hernia. That means we're damaging the floor, I think. That may be a bold statement that's not true. What about recurrences after lap hernias? These are such old studies. This, I've been giving this talk for like a decade. I need to update this slide. I will remem remind me, there's so much better papers now. Oh, here's some. 2019. Basically, the recurrence is so low. So, here, um, this was, let me go up. So, we've got 0.2%, 1.5%. Now, Felix Shear, who honestly was the father of lab hernias, had a high recurrence rate, but give him a break. He was the, uh, early on, early created uh a technique of the Z-stitch that we now know doesn't work as well. That's why they had that recurrence. But now that we know how to do it, The recurrences should be close to 03. almost 1700 kids. Almost 4-year follow-up, 2 points, um, um, uh, the, let's see. So 4 year follow-up after open, 2.5 year after lap. They got a contralateral hernia, so a con a metachronous, not, not recurrent. The other side, 3.8% in open. Um, without lap look, open with lap look, 0.9%. Um, and the recurrence was 0.8% in open and 0.3% in lap. So the recurrence is about the same. If anything, um, um, in, it's lower for lap. Um, here's another paper, 0.75. It's less than 1%. Recurrence should not be an issue if you know how to do this. That's the point. No one can use the argument of recurrence. I know that Sharif Emil presented at ASA that they had a 10% recurrence rate in Montreal. Um, I would argue that they, they need to look at their data because the larger series don't show that. So that was, uh, an outlier in my opinion, and he and I had a fun debate through social media because I would say that it's so different that we need to learn from it. I believe the data, but we have to wonder why. Why was there a 10% where everyone else is pointing to under 1%? Um, all right. This is the part most people wanna know about the techniques. Um, Oh, Victor's back. Do we have, let me know. Isa, interrupt me anytime. Don't let me go on talking if Victor is back. Let me add him to stage. Do you want me to add him now? Let's do it. Victor. Victor, how are you? Hey man, how are you? Fine and you? Good. What's going on? Everything's OK, hearing about your, uh, the lab. I'm really convinced about the lab in a repair. As you say, I'm not trying to Uh, convince anyone that it is the better way to do it. It's the better way to do it for me right now, but I think I will change in the upcoming experience coming on. Uh, I haven't been experiencing anything about. Pain uh in my patients. The outcome has been, uh, uh, great. Just one recurrence. It was my second case, and I think it was part of the material I used. I used nylon. And now I changed to 80 point, so, uh, my outcome has been great. 2 patients with terrible incarceration problems, 2 teenagers. But it has been resolved. With the laparoscopic per percutaneous closures, so I'm convinced about this. I'm here about your new incomes, your new outcomes, and how you changed your, your mind about. Your performance. Yeah, well, let's, let's, this is great. I appreciate, uh, your experience, um, um, so thank you for the, the comments. Um, yeah, Isa, were you gonna say something? Yeah, we have a couple more people. I'll add them to the stage. That's good, yeah, and then we'll show some techniques after that. So who's here? Uh, We have Doctor um Angeliki Kariki, I'm, I apologize if I'm mis mispronouncing names, and Doctor Iliana. Um, they're both, they're both live, but they have their cameras off and that's OK. You guys wanna go ahead and, uh, make a comment or ask a question. Oh no, I just think this is wonderful. I look ridiculous because I was helping my friend get ready for a hair styling thing, so I look crazy, um, but I'm very excited that you're hosting this, and I think it's wonderful. So awesome. All right, yeah, if anyone has a comment or question, just let us know and we can, um. Bring it out to the stage, um. Awesome. OK. So let's um keep going here then. Um. Let's see. All right. So this is the part everyone wants to know. So this is CK Young. CK uses an all. Um, and if anyone has talked to CK in a while, I don't know if he's still doing the same technique, but he's done probably more than almost anyone in the world. And he's a magnificent surgeon, and I love seeing this video. He takes this, this, this instrument. Um, and he passes it around. It's, it's threaded with a, a nylon suture. Now, here he comes over the vessels. Um, which is always easier to pass over than the vase for those who've done this. Um, it, that space is easier to get. He does not hydro dissect, he just passes this around. And then he pulls the suture out. So he passes over the vas and vessels, he pulls that back out and then goes back in medially. And grabs that suture. When I saw this, I was like, this is so beautiful. I tried it and it Wasn't as easy, this part. Especially if you're with trainees getting this thread in the hole, uh, that's CK, one of the best laparoscopic surgeons in the world. You can imagine how painful it is to watch, uh, and then it pops right back out. So I didn't love this for that reason, but it's a beautiful technique. And his point he makes here is that you always have to pull the, the peritoneum down so that the suture lies right at the internal ring. So that's his important point, and then he ties it down. So that's CK's technique. This is using a um Garrett Allen and Scott Bollinger. This is using a um Oh, I don't have that video for some reason. So, uh, it's OK. No one does this anymore, but the idea is you could pull the sack and put an endo loop around it. I'll find that video and get it for you. This is how I started. This is the technique I learned. So I learned lap hernias. I went and spent time with Craig Albanese in uh Stanford. They take, they took at that time a huge CT needle and passed it around from the outside. I wish I had a video showing, but from the skin through, they pass it. They skip over the vase and vessels and go back outside. So now you have the end of the needle and the tip of the needle showing up through the skin. And you pull the needle almost all the way through, and then you take the, before it comes all the way out, you take the back of the needle and push it under the skin to the original insertion site. So it goes around and then back under the skin and pull it out and tie it down. And I started this way. And to those comments, I had so much pain and a recurrence in my first case. Pain and recurrence, I think I grabbed way too much tissue. Um, and so I stopped with this. It was when Steve Rothenberg showed me about Darius Petkowski's hernia repair technique publication, and I've since learned that, uh, Takahara from Japan also published this technique. I still use this technique today. Um, the idea here is it's percutaneous with needles. So let me, um, show you how this is an animation. It's not a great animation, but let me show the idea. We start off with an animation that demonstrates the basic operation. You start off with an 18 gauge spinal needle through a tiny 1 millimeter incision. We then thread a prole suture through the needle and pull the needle out. Then entering through the exact same incision, we come medially and slide another loop prole through the first loop. Then when we pull the first loop up, it acts like a snare pulling the second loop. Around the So this is a video that, that for some reason I still use, even though this was when I was in Corrientes, Argentina, um, and they were filming the monitor. So, it stops at the very end, but here it is, I hydro dissect. So I take a tiny needle with numbing medicine, with marcaine or lidocaine, and I inject to lift the peritoneum off of the structures. Then I make a tiny incision and I pass a curved spinal needle that's threaded with a And uh a prole. And I pass it now into that area that I hydrodissected. You have to see your needle. If you see your needle, you know you're not grabbing anything. And then I pop out through the peritoneum. And then I thread the suture through the needle. Here's me threading it through the needle. The reason I like this old video, this is probably 1012 years old because it shows the open and the internal. Um, and I thread the suture through. Then I pull the needle out. And I come through the other side. And this Um, You can choose to get over the vase when you do the 1st 1 or the 2nd 1, whichever you think is easier. You don't have to come through the exact same hole, but it's nice if you do, then you put it through the 1st loop. Now, what I do then, I'm gonna pause this. What I do then is, oh. What I do then is, um, Let's see, let's pause it here. I take this loop and I pull it tight around the needle. That gets all the spaghetti out of the abdomen. So now you have no suture in the abdomen, and then I pass the second suture through the needle. Now, this video, who was recording it ended early, so I take another case to show this part. So you just push the, see how it's, the first suture is tight around the needle, then you push the second suture out, because it's tight around the needle, now it's tight around the suture and you pull it up. And that's it, OK? Now, How does this work? Does the stitch need to stay there forever? Or does the scar form, or does it work like a Seton? Does it cut through and cause a scar? So, one day I was visiting um these knuckleheads down in Santiago, Chile. So that's Miguel Gilfon, Patricio Varela, and Jorge Godoy, and I was visiting them down in Santiago, Chile. And Jorge says, come look in the operating room. I wanna show you how we fix hernias in girls. So we go in the operating room, this is him. And he goes in, and he reaches in, this is a girl, not a boy, and he grabs the sack, and they pull it internally. And I'm showing this now to make a point on why I think, how I think this lap hernia works. And all they do is cauterize. And they destroy the sack. And it destroys it, and we, before we walked out of the operating room. We made a joke that stuck. We called it burnnia instead of hernia. Uh, and a lot of people do this now. I've even done it in girls, where you destroy. The point is it works. So, it's just the, the scar that works. So, there's also Mario Roelme. To make the point even more, he does no ligation, just resects the sac. And um if that's the case, and there's no ligation, just resection, I think, again, just destroying the sac or making a scar might be the reason hernias work, whether open or lap. So to test that theory, back in 2011, We took rabbits to see if we could recreate scar and see if that's what causes it. So what we did is we took a rabbit that have hernias, and We, on one side, did suture alone. And on the other side, before we did the stitch, we caused cautery or uh injury anteriorly. Just right here, not where the cord structures are, just anteriorly caused injury. And then we use that technique seal, which I was using at the time. And then we survived the rabbits for 2 weeks, and then some for 4 weeks. So What we found, we compared the two, we would put the laparoscope in and at a very low pressure, and then we would cut the stitch. On both sides. Then we increase the pressure really high, 36 millimeters of pressure. What we found is that The side with suture repair only, no scar. 25% stayed closed, so 75% popped open with that high pressure. 87% stayed closed with trauma and stitch. So even after cutting the stitch out, 87% stayed closed. Then we waited two more weeks, remember the 4-week group. In this group, 17% stayed closed, the rest popped open. But in the side where we caused injury, 100% stayed closed when we cut out the stitch, showing that It's not the stitch, it's the scar that forms from the stitch. Even if you cut out the stitch, 100% stayed closed. Now I'm gonna push against myself and say, if this were true, then absorbable suture should work. It doesn't seem to work. We tried it in the rabbits and it didn't work, and there are people that tell me they have recurrences with absorbable suture. So, I don't understand. Is it that it absorbs too fast? I don't know why. Maybe we try PDS and it's like a longer absorbing. I don't know why. Um, or maybe it's because the absorbable sutures are monofilament. I don't know why, but we do know you can cut the stitch out, and they don't recur. Um, So, Does suture matter? We did find that we tried 3 different suture types, and we removed the suture, and we found that the braided ones. Had a, a much higher ability, if you put in a monofilament and remove it. It still failed, even at 6 weeks. So for some reason, you need a braided suture. So if there's a braided absorbable suture, we think that would be the best, a braided absorbable suture, because we know that the braided sutures cause the scar and monofilaments do not, which is probably why the absorbable model fails. Um, So, this video, Iowa can post in the chat, and there's a button for it. This video is on YouTube. And if you just type in, if you forget it, just type in my name and hernia, and it usually shows up. This is the full video on the, the way I do it, sort of bringing it all together. And I love, when I play the video with audio, are you able to hear the audio from the video? You should. Let's go ahead and try it. OK. We start with an 18 gauge spinal needle. Some people use a two-way needle which has a more blunt curved tip. I then curve the tip. It's a gentle curve because if you make it too sharp of a curve, the prolene won't slide through. I like to use a prolene suture initially because it's firm and it slides easily down the needle. I cut the needle of the suture off and then you'll see these little curved tips. I cut those off also, so you're left with two straight tips which more easily slide through the end of a needle. Here I line the tips up and I put it through the tip. Some people crimp the loop and put the loop through the back end of the needle. That works fine as well, but I have had that tear of the suture before, so I like to go retrograde like this. The two ends come out to the back as you can see, and then I pull the loop. And I pull the loop just till it stops at the tip of the needle. If you pull it too far, sometimes it is a little difficult to advance. Then I inject marcaine into the inferior portion of the umbilicus, and I usually use a 3 millimeter camera. So this is a 3 millimeter incision. Because of that, you have to use a V approach. Here's a 3 millimeter step trocar, and I insufflate the abdomen usually to 15 millimeters of mercury. In a large adult sized patient, I use a 5 millimeter camera. Then I've added this instrument, which I used to not have in my procedure, but this is an extra 3 millimeter Maryland detector that I put in through a stab incision. No matter how large the patient is, I always use a stab. And we do this because in our study in rabbits, we found that in the rabbits that we caused injury and then did the repair, it was much more durable. In fact, even if we cut out the stitch after 12 weeks, the closure remained intact. Uh So the, the injury really keeps things closed. So here you can see the cord vessels, the vase, and the vessels. Then we find exactly where we want to make our incision in the groin. The incision is ultimately going to be the size of a needle, but to find this spot, we're looking laparoscopically. We match up to find the 12 o'clock position on the outside, and then we make a 1 millimeter nick with a knife just enough to get the tip of the needle through. Then prior to doing the repair, I hydro dissect with buppivacaine. I usually use 0.25% or 0.5% if it's a larger patient. This dissects the cord structures away from the peritoneum, as you can see here. Sometimes if it's a very small patient, I may even dilute out the Marcaine so I can do both sides. It's a bilateral hernia. Then I take the threaded 18 gauge needle and I pass it first laterally. I, uh, you can see here that I'm clearly dissecting above the cord structures. I'm always standing on the patient's left, left side facing their feet. I have the monitor at the foot of the bed. That's whether it's a right or a left side hernia. I always Stand that way and I always go lateral to medial first. Here you can see I'm clearly above the cord structures. I usually stop just short of the vas deferens when I'm going from lateral to medial. Then I thread the loop through. And I pull the needle out. And then I secure that with a hemostat. You want to make sure that if you push the loop through the needle, you don't pull it back into the needle because then sometimes it's hard to push it back through. You want the loop just at the very tip of the needle. Then I go immediately. I will use the Marylin to help me give tension on the peritoneum. And you can see here that I keep making sure that I'm above the vase. If there's any question, I will skip out over the vase and leave 1 millimeter of tissue. I think that that is not a real problem to leave 1 millimeter of tissue. That needle goes through the first loop, and I snug the first loop around it, and then after it's snugged around, I push the thread through the second needle, through the needle. Then I pull the needle out, so now my second loop is threaded through the loop of the first loop, and I pull that first loop up like a snare, and it pulls that second prolene all the way through circumferentially. So now you have loop prowling and all the traversing all the way through. Now you could be done and just tie this down, but I don't like the thick feeling of a of the knot of a proling. The patients complain. Plus we've shown that when we use a braided. Non-absorbable suture, the repair is better, at least in rabbits. So once we've got this around. We will exchange the prole for an etha bond. You do have to start with a prolene because the etha bond is not stiff enough to be threaded through the needle. So we do this and then just do a quick exchange at the end. Like I said, you don't have to do this, but then you just pull it right through. It takes just a minute. You do have to evacuate the air out of the scrotum, uh, an inguinal canal prior to doing this. So I usually have an assistant push down and then I cut the Uh, ethebo, which releases the prolene. And now you have the 3 ends of the. Ahabo suture. You can use silk or Ticron or any suture you want. I do think you need to use an um a non-absorbable suture, um, although, like I said, if you had injury, you may not even need to. Then I cut this right above the knot. And uh I usually put about 4 or 5 knots in. On each. And then I pulled the skin. So that's a double ligation actually, because we looped it and cut it. And then here you can see that the cord structures are well away from the repair and it looks just like it does if you go in laparoscopically after an open repair. Then I close the umbilicus and the other skin incisions I just closed with surgical glue. They're too small to stitch. I do a little stretch to make them a straight line and I glue them together. All right. So, um, we start with Technical considerations, someone already mentioned a block, we do that as well. Um, but we do it preoperatively with obviously, like, you know, Marcane, not, um, You know, just a temporary block. Um, and, uh, you could do, sorry, the other, this is the question about the block. So if you do like a, um, Um, like a, a, a, a block, anesthesia does a block, um, and a caudal block. You can do that, or I tell them not to, and I use the marcaine, the local to inject the peritoneum instead of the, so, I don't know, we were gonna study that, we never did. Um. And then I stand on the left side of the patient always, so my, because it helps me with my right hand always being dominant. It works left or right. Some people switch sides, there's no right answer. I always, before I start doing anything, I take a tiny little 24 gauge needle and just stick it in the groin to see where that 12 o'clock position is in the um inside, so I know where my 12 is. So I use a finer needle, pre-bend and load the needles. I do it ahead of time so I can go faster. I do use two spinal needles, but that's expensive. You can just do one at a time, it just adds more time cause then you have to re-thread the second one, the second time and you have to wait for them to re-thread it. Do, don't put it at an angle, make it a bend, cause if it's an angle, the suture will get stuck as you pass it through the spinal needle. So you can either crimp the stitch and push it through the back, or um, Here, I'm gonna um So, you can either, if you have the needle, you could crimp the stitch and push it through the back of the needle. But when I used to do that, I've had it break when I crimped it, and it got weak. So, now, I just take the, the two free ends, and I put it back through the tip of the needle, but there's no right way. Um, and, um, Make sure you make your skin incision big enough, not too big, but if it's too small, you might get a, by accident, get a skin bridge when you go in with the second time, you, you wanna make sure you go in the exact same hole. So make sure it's big enough that you find the hole and stick the needle through the exact same hole or you'll get a skin bridge. Um, I take the needle and I pop in and then pull back cause, uh, you do have to go through that pop through the fascia, and then, then you have the smooth gliding. Um, so I do the pop and then pull back. Um, and it's not a, you don't come around like a circle. It's almost like a V. So you come down, pull out the suture, come the other way, pull out the suture, so it's like a V as opposed to a true circle, for me. Um, I, uh, typically go lateral and go as far as I can, so you don't get the inferior epigastric. So I go lateral, I go over the vessels, if I can get over the vase and I put that other instrument in. You don't have to, but I like to pull the, the peritoneum and then push it over the vase, and then the medial one just goes straight down. It's a lot easier. Um, it depends on the patient, which, which you do, um, lateral, medial, um, and which needle ends up going over the vase. By the way, if you can't get over the vase, just skip it. If you cause the scar and use a braided suture, Um, you should be fine, even if you don't, even if that's a little bit of peritoneum, you don't have to try to get under the vase, under that peritoneum over the vase if it's not easy. Um, Um, I use the Maryland to stretch, um. I already talked about all of this. Oh, the exchange to Ehebo. So, I use a prolene, but then I switched to an Ehebond cause the prolene is easier to use the passing, but the ethebo is a better suture to have in cause it's braided. Um, and, um, Oh, the small PPVs are tough, and Some people would just say leave those alone. Um, so, uh, you know, those little tiny holes are sometimes really hard to repair. Um, OK, this is critical. So, um, I think it was Rafi that said that you put a loop and then you put a straight one through the loop. Perfect. I don't do that because I like to doubly ligate, so I put a loop through a loop, so I have two stitches going around. But the problem is, some people get, some kids will get, this is a really important point, suture granulomas, the stitch will pop through the skin. That to me happened early on in babies. And I think it's cause they have a tiny thin amount of skin and tissue above the knot. So now, I do a single knot, a single ligation in babies. So in that situation, yes, you can just pass a single one through, or when you have the double, just pull one end through so it's a single now. But I don't put double ligations in babies, only older kids. Um, I have someone push on the scrotum before I tie down, so air isn't in the scrotum. Then I pull up the skin to release the knot. I use glue, make sure your testicles are down at the end of the case. Um, and then, you don't have to close the sac, you can remove it, and here's the argument to that. So, It's the towel on the door. If you have a heavy door, and you remove the towel, the door will shut. So the thought here is if you just remove the sack, The muscles will shutter closed. So some people believe, instead of ligating the sac, you just remove the tissue and the doors, the muscle will shut or close. And that's why Mario Roelme and others Uh, just remove the sack, no stitch. We know this works in orchidexes, so, um, So, um, You know, uh, you, you, you don't have to, um, you don't have to, um, Ligate, you can also just um remove it. The hydrocele. I've done this laparoscopically, this is the video. So, um, I do hydroceals open, but if I can, if they lend themselves to this, so, um, There's a little PPV there, but interestingly, So this one was a communicating hydrocele. On the other side. was a non-communicating hydrocele. So, I just pop it, remove a little bit of the sack. And then do my open my lap hernia repair. You can use the scissors or cautery here, just make sure you're anterior, so you're not near the cord. And you pop in Drain it, and then you can excise some of the tissue. So I excised some of the tissue here. And if anyone wants this video, I can send it to you, and then I do my lap hernia repair. So here's the hydro dissection. And then I passed the needle. You've seen this before. OK. Femoral hernia, um, I don't, so, here's the important point, really important point. I'm gonna go on full screen, so I make this point. Um, This is for indirect hernias. This does not work for a muscle problem. I don't believe in a direct hernia or a femoral hernia, you should do this technique. This works because It's a high ligation. So, what you need to do for these is, if I go in and I see a direct hernia, I open. I open and I do a muscle repair. Now, some people believe they can do a lap muscle repair. I'm not, or you can do mesh, a tap or a tap. But if a femoral hernia, I learned this from Jeffrey Lucas, I just take my Maryland, put it in the femoral hernia, and I make an open incision on top of it and I fix it open. I don't do muscle repairs with this technique. This is just for um Just for um High ligation. All right. Do we have to operate? Um, so, this shows that what happens to, um, to hernias, to the incarceration over time. This is incarceration. So you have a high incarceration rate early on, but it really drops. You know, about a year of age. So, some would argue, you don't even have to operate because her incarceration rates really dropped. Um, then I wanna talk about adolescence, so let me move myself here. Um, how would you guys fix this? Send you an adult general surgeon, open high ligation, lap high ligation, lap mesh repair. Open mesh repair or open muscle repair. So I think, Isa, do we have a poll for this or no? I think so. So, send to an adult surgeon, open high ligation, lap high ligation, tap or tap. Open mesh, open muscle. A rainbow So, uh, Victor says lap mesh repair. I, I, I, um, that we're gonna talk about that, um. First of all, I don't do those very often, so I don't feel comfortable. Probably some people do a lot more. I haven't done it since residency, but I wouldn't do it anyways, even if I knew how, and I'll show you why. It looks like it's all over the place. Um, Yeah, OK, let's go back to the presentation. So, um, So, we pulled thousands of surgeons, and one group. And another group looked very different. One group did a muscle or mesh repair. Um, I'm sorry, one group did mostly, um, the high ligation, and the other group did mostly mesh, mesh or muscle repair. And they both studied the same books and anatomy books. The difference is how they were trained. So it just tells you it's what you were taught, not what's right. And if you look at this person and this person has this repair, we call it a patent prosthesis. And we know that, you know, we think that the testicle goes out and the peritoneum just invaginates. So, so we call it a patent prosthesis. We don't, it's, you know, um, and so we treat it with high ligation. But this guy, who has the exact same hole, We call it a hernia, um, and we've treated with mesh. And, um, Why is it when the whole is the same, we treat with mesh in him. And not the, the children. So, um, I would say that here's the problem. Everything, they have mesh just like Victor's, so, mesh makes sense for some, but not everyone. So, they would say, oh, direct hernia, mesh, indirect hernia, mesh. And I would say mesh makes sense for direct, but maybe not indirect. Unless you believe in this pond theory, that even though there's a hole here in an adult, it's weak around it. And so, if it's weak around it, you do need to put mesh even for indirect hernias. I'm not sure that's true, um, because I think it's more like this, that It's not weak around it, and we should be able to put just a high ligation, even if it is an adult. And that's controversial. So, what I would say is if people think that adults or adolescents should get mesh or in a different repair than children, when? When do you switch? This child, this child, this child, this child, this child, this child, when do you switch? How do you know when to change your approach? Age, weight, size of the ring. This guy, Mike Rosen, hernia surgeon, adult hernia surgeon, said, If you're gonna argue to me that adolescents and adults should get the same repair you're doing in kids, show me what their success is in adolescence. So, Sean Saint Peter and I did this multi-center trial where we looked at And if you do high ligation in adolescence, does it work? And we found that um we had about less than 1% confirmed recurrence, 2% suspected. So, we think it's very low recurrence. So we do think that even in adolescence, an open hernia repair, um, high ligation works without doing mesh or a muscle repair. Um, but when do, uh, when does it change? Is there a point? So what we did is, we did a study with a pediatric and an adult center combined our data, and we saw that Early on, almost all hernias are indirect. And as they get older, You see more directs later on. This tells me that the floor changes. That the floor starts off very strong, and over time, the floor weakens, and you start getting direct hernias. So, the question is, when is the floor weak enough that we should start doing an adult type repair? Um, and There we saw a statistical inflection point around this age, but we actually saw the first inflection point around this age. So we think statistically, this is when you start seeing substantial weakness of the floor. And maybe that's when changes should happen. Um, but what I would tell you from this is. I will fix almost anyone with A laparoscopic high ligation. What I tell the families is. There's almost no downside. Why would you put mesh in if we think that this will almost certainly work? There's a small chance it won't, then you can get mesh. But I would go for this and take the chance it recurs, but I give them the choice and I send them to an adult surgeon to get another opinion. Um, So, this is a patient that I'm just gonna fly through this, had the same repair you're used to. The difference is, this is like a 70 year old patient cause we did a trial in adults. And Um, we did this study in Norway and now they're doing, uh, this repair in adults and they have almost no recurrences. So we do believe that the high ligation works in a subset of patients, not just, um, not just kids. And so this is what we did. We trained them on how to do the, the, the hernia repair, and then, I mean, now they, uh, they've submitted zero recurrences. So, Um, that is the end. Um, I am going to, uh, go to Hold on. Here. And we are gonna now take questions, and if anyone wants to uh call in, please join. Um, but I will go through these and um, Please, if I, if I talked, if I mentioned to any of you, uh, to come on stage, please come on cause I'm sure we would love to hear the, the thoughts. Um, Gabriel asked about, can you put a lap stitch in when you do ernia? I do. I do the bernia and then I put a stitch. Um, now, we talked about pain. The cautery causes some discomfort, by the way. Injury to the peritoneum does hurt. So, uh, doing no hernia or no injury or no cautery is the least painful. When you add the injury, it does cause a little more discomfort afterwards. So keep that in mind, and the burnia, I'm guessing hurts. Um, Um, invisible thermal injury to the vase. The reason I don't, that was a question that came from Facebook. Um, the reason I don't worry about that is I'm so far away. I don't go, I don't cauterize anywhere near the structures. I cauterize only at the very top. And if you're worried, just take a scissors and cut. You don't have to to cauterize, but don't go anywhere near the chord structures when you do that. Um, and, um, let's see, uh, next question. Doctor Jorge Correa from Braga has some um tool, um, Has something with the idea of cauterization of the superior of the internal ring. Um, Yeah, I guess you're saying that he has a problem with it. I don't know, Mar Marcio, I don't know what you're saying. Is he saying he doesn't like the cautery or he does? Um. Aren't you scared to injure the, the ductus deferens with the trauma car? No. Again, same thing, burned. Um, I'm nowhere near it. If you're near it, you shouldn't be doing it. If you're worried, just cut with a, uh, laparoscopic scissors. Um. Um, I wonder why the Japanese dedicated LEC needle, um, hasn't caught on to the States. Um, Yiting, I, that's a good question. I tried it. I just found it wasn't any easier, but I'd be willing to try it again. If, if you're really thinking it's great, um, I, I'd be absolutely willing to, um, to try that, that needle again, um, but it, I didn't find it so helpful. Um. So I, people ask, is there a risk of vase entrapment? OK. So this is like a physics thing. We actually, we're gonna find a physicist to recreate this in a model. If you put the suture, if the vase is here, and the ring that you tie, how do I get this on camera? If the vase is here and you tie your suture and you tighten this, It shouldn't tighten the vase, cause it's above it. So physics wise. It shouldn't injure, and you should never have the, the needle going under the vase. If you can't see, and you're not sure, just, just skip that area, it's fine. But if you hydro dissect, you can always, you should always see your needle clearly under the peritoneum, and if you can't, then don't take that chance. Um. Uh, what else? Um, anyone, uh, to Yiting's question, if anyone's used the, the LPEC needle, let me know. Um, another, uh, fact favoring the injury theory, when we operate open or lap orchidopexy, exactly. The orchidopexy is the example of why we know that you don't need to ligate and the injury is enough. Um, we leave the sack open and we don't see hernias. That's a, a great point, Jose. Uh, Mark Wilan, I haven't talked to you in a while. Um, I just put one end through the needle and leave the other end out. Um, I'm trying to think of what part of presentation you said that, um. I think you're probably talking about instead of the loop, but um. Uh, epidural needle, um, we do too. A spinal needle is what we use. Um, Mindy says you can preload the second pass of the needle with the Ehabo saving a step. Again, yes, you can. Um, Uh, but in a baby, yes, I would recommend a double ligation in someone non-baby. Um, Yes, I use, um, you can, whatever needle you can do this with, um. Some people say different needles are cheaper, um. That's a good question, Iliana. The, the question of saving OR time by having two needles threaded ahead of time. Um, someone like Mark Wilkin would have to answer that on how to, how do we know about OR time value versus the cost of the needle. Um, I don't know how to measure that. Um, Ethelbo is too soft and difficult to thread, I agree. And that's why, oh, I see what people are saying. If you load the eel bond, you don't have to exchange it. I use the prolene, cause it's so much easier to work with, and it takes 2 seconds to just, once you have the two threads here and the loop here, you just thread the ethebo through it and pull it through, and you exchange it. It's so much easier than um playing around with the eelbo, in my opinion. I, I find it's floppy and just uh just like I was just said. Um. Uh, by eating, um. Alberto Torres says, I have 5 cases of direct hernia fixed with this technique, with 2 years of file without recurrence. How do I respond to that? That's amazing. If we think this works, I am all for hearing how and why. Intuitively, it doesn't make sense to me because you're not grabbing muscle. You're grabbing the peritoneum in this technique. Whereas a direct hernia is a hole in the muscle. The muscles are opposed, there's a hole. So I guess I'm not sure why this would sustainably work as they age, but I think you need to stitch the muscle or put a patch there or something. I'm, I'm afraid that, that just ligating the peritoneum will fail if it's a muscle defect. Um, And then, there's gonna be recurrences and people will say that the lap hernia doesn't work. So, that's another thing. Um. What did I say about femoral hernias? Yes. With a femoral hernia. I don't believe that this works unless you're grabbing muscle. So, I don't repair femoral hernias this way. I see the femoral hernia. I take my Maryland, I learned this from Jeff Lucas. I put the Maryland in the femoral hernia, so it's poking up through the skin, cause there's a hole, you pop it, and you could like feel it through the skin, you're Maryland. Then you take out your lap stuff, and you go open and you make your incision, so you have a very focused incision over the femoral hernia, and you could put two stitches in. So it's just is a minimal way of, of finding the hole on the outside by putting your Maryland in. Um. Uh, Ricardo Alberto Rojas Valdez, you said, I think it depends on when the hernia appeared. Remind me what I was talking about at that time. I apologize. Um. If, uh, if I found it myself in a center without 3 millimeter pediatric set, is it OK to use the 5 millimeter instruments? Yes. 3 millimeters Better, but to be honest. Uh yes, I would use 5 millimeter. I don't use trocars. I just make a stab and I push the instrument right in through, but you can use a trocar, but yeah, 5 is fine. How do you treat hydroceles in the same way as a hernia? So I, this was probably before I showed that video. Again, if you want it, I can send the video. Um, I just pop it, I push it in. If it's, I pop it, I cut a little bit of the tissue out, and then I do the lap hernia repair. Um, cause the, the, the sack goes back in and then it looks the same, once it's back in. Um. I was doing all with intracorporeal until one recurrence for a very large ring, and then I closed the rings now extracorporeal. I started intracorporeal too. That's how Steve Rothenberg originally taught me. I think he does this now. But I found it like painful to like go and sew backwards upside down on the anterior part. I just found I found, and then you don't need to put 3 instruments in. I don't know, I found this more. Appealing, but, but yes, you can do incorporeal, either one. Persian adults, um, although I forgot who it was that said we shouldn't settle on, you could do whatever you want. We do need to study them, that's hard and ede sometimes. Um, Persian adult indirects are OK, but the nerve entrapment is a more common issue. Again, I think if you only get peritoneum, and you see your needle the whole time, the only question is, could you get entrapment? In the area above the ring, and I suppose that could happen, but if you go in the exact same spot and minimize the group, the, the clumping of muscle that you go in straight down, go to the side, come in straight down, go to the side. It's really hard to get a nerve because it's like a needle area that you're going straight down through. You're not grabbing stuff anteriorly. I'm curious if others have had a different experience. Um, Um, people asked about the bernia. Don't use bernia in, in boys. Um, so you should not risk the vase burn cause you should not use bernia in boys, only girls. Um. There's a question. In Ireland, we performed the bernia, but incorporeal stitching. Agree, you, I agree with that. Um. Some articles suggest that in adolescents with indirect inguinal hernias who have never been symptomatic, it is better not to operate. Yes, Jorge. I was shocked when I heard this from the adult hernia surgeons. They tell people now. If you're asymptomatic and it's not bothering you, the risk of incarceration is less than 1%. It's probably OK to leave it alone. So, yes, you don't have to operate on all hernias. And now, when I showed you the data on babies and children, we even know that children have the same incarceration rate as adults once they get to 1 or 2 years of age. So, even for us, you could potentially say you don't have to operate on this. Very controversial. Um, Why don't you use an endolo? Because, um, First of all, I don't, I think it costs more money. Second of all, I don't know how easy it is to bend the endo clothes. So, um, whoever, uh, AD is, um, If you've, if anyone's used an endo clothes and have been able to bend it to get the curve, uh, tell me. Um, Diego, if Ehaban isn't available, what's the second option? Any braided, non-absorbable suture. Maybe any braided suture, period, but any braided non-absorbable suture. It could be anything. Um. Uh, have you ever had a femoral nerve block after using hydrodissection? I have not, because I only hydrodissect where I see my needle. I don't just blindly go. I stick my needle, I see the peritoneum, I inject. I'm not blindly sticking it. I see my needle as I'm injecting it. Uh, Doctor Gaffar, can you do a one-minute brief summary of what you do? Basically, try laparoscopy for everything indirect, including incarcerated hernias. Don't fix the patent prosthesis at the time of appendectomy. Femoral hernia should be fixed, open in kids. Yeah. Um, yes. So, um, I don't fix the PPV at the time of appendectomy. This is a great point, Doctor Gaffar. We should give like a bulleted summary of every point made here. Maybe we'll send that out as an email after. Isa, remind me. So, yes, um, Um, try laparoscopy for everything indirect, including incarcerated. Don't fix the patent prosthesis at the time of appendectomy. Again, that's just what I do. Um, direct and femoral should be fixed open in kids unless you know how to do a tap or tap. Um, but again, that's what I do. Um, no age limit to lap high ligation. Now, let me be careful with that. When they become Teenagers, I have the conversation with the parents that we don't know very long-term outcomes. We've got short-term 5-year outcomes where we published with 11 centers and it's very low recurrence. So, I tell them that our initial studies seem very low recurrence. Um, and that I recommend doing the lab because mesh has pain. Mesh can cause infertility if it, um, scars the vase. Um, it, it, it can migrate, so I don't like to put mesh in. And I get adults calling me from all over the world that have heard me say this and want me to repair them. Um, laparoscopically. We don't have adults at our house, we can't do that. But it would be great if there were adult surgeons that would be willing to do the laparoscopic non-mesh repair. In patients that want it, um. Uh, in, in smaller children, would you prefer, uh, the Mitchell Banks over the Ferguson? Abby, I don't know those. I'm sorry. I don't know the Mitchell Banks or the Ferguson. I, I, I feel I'm stupid, but please tell me what those are. Someone can tell me what those are. Um. Debbie Varella, uh, let's see. No, there's no comment. Uh, good morning. Um, don't use intracorporeal knots in any case. I don't, but I'm not opposed to it. Um, I just don't, but that's me. If someone said, I would, it would be fun. I, I just haven't cause I know this technique, so I can't think of a reason when I would do that, but I'm not at all opposed to it. Um, in a pantaloon hernia, is laparoscopic possible? No, because you You, you have a direct hernia component. For me, now, Alberto would say, yes, and there are people that are talking about doing a lap muscle repair. I just don't know how. Um, The vase is in direct contact with the posterior wall of the internal ring. Ligating the stitch will angulate the vase. So Ayad, here's what I want you to do. You know it would be amazing, I would love for someone to watch laparoscopically. While someone is doing an open high ligation. It looks identical. So, you're going in from the outside, and you're pulling up the sack. And you're getting, dissecting it down, then you tie as low as you can, and you drop it in. It anatomically should look identical to the lap one. So, You might be angulating, I can't say that for sure. I don't know, but why is that different than the open repair? The only question might be that because maybe in the open repair, you're dissecting it away more. Maybe. So maybe that's a valid thing. I don't know. It's a good question. I don't know. Um, Doctor Gaffar, braided sutures should be used, but maybe burning only is fine. Um, Um, Burning only is maybe fine in um And it is like a burn out in girls. I, I don't think you can burn only in, in boys, because you only can burn the very top in boys, just a little bit. Uh, so in boys, I think you have to put a stitch. In girls, you could argue just just destroy the vat, destroy the destroy the sack. Um, but you, you, in boys, I would always put a stitch. I put stitches in girls too. And, um, you know, maybe that's an example of where you could do an intracorporeal stitch, um. Because, you know, maybe less chance of spitting the knot, cause the stitch is internal. Um. Fix, um Um, fixed premie, I know, um, oh, so, uh, Doctor Kafar is still asking about summary points. Fixed premie hernias depends on the parent preference. Um, It's not just, so, the timing of when to fix a preemie hernia is not just the parent preference, it's your judgment of the parents. Do you trust that sending a preemie home If, if they saw an incarceration, they would be close enough, they would be able to manage that. If there's a question on the responsibility of the parents, I would just repair it. Um. Um, Uh, Victor, why only one suture and preemies? Because the distance between where you tie the knot and the skin is so minimal. Um, that the few suture granulomas I've seen have been in the babies. So that's why I have less of a knot. I like, I don't like two big knots. In the baby. So that's why I do a single ligation, tie it down, and I only have one knot, less chance of a granuloma. So maybe there's another question of maybe those are the ones we can do intracorporeal. Um, but, um, Good questions. Um, So It says, anyone that's in Streamyard, Isa, bring them up now. If anyone's in Streamyard, bring them up. Um, I would love to have anyone talking with me here. Uh, oh boy. But Mark is sideways. Why is Mark sideways? I don't know why it keeps flipping sideways. Now you're upside down. There you go. There you go. What's up, man? How are you? Good. How are you? Missed you at iPad. I know, uh, it was a great meeting, great meeting. We had over 500 people. It was awesome. So a couple of things, uh, just I wanna ask you about. Um, so what I was talking about when I put one suture through, so I, I, I stopped looping through the spinal needle because it's a pain in the rear. So I just put one end through and, and then use it like the, now I'm upside down. Wow, I'm not sure what's going on with my iPad here. Keep turning it. Yeah, I'm gonna, let's see here. There you go, there you go, yeah, um. So I just put one through just it looks just like the all that, you know, CK's all, yes, and it, I was afraid it would shear the stitch, yeah, because you have one end coming out, but it doesn't. So Mark, are you not 11, you know who does that also Oliver does that. I don't know why your thing keeps turning. Um, I have no problem with that. I love that, but I like to double ligate. You don't double ligate. No, no, I still pull, so I still pull the loop through, so I don't pull it out through. It still works. How so, so I, I go in with one, and then you end up with a loop in the back inside intracorporeally, right? And then I go through the other side with another stitch. Wait, wait, Mark, as you pass one suture through. Yeah. It's not a loop, it's just a single thread. No, I have a suture through, and then I pull it back out. I have a hemostatin on the outside. So I have the, the suture looped in and out. It goes through the needle, and then I take the two ends and hemostat them, so I have two sutures going through. Do you follow? You have your needle in. First needle. First needle, but the suture goes in the needle and out the needle. No, uh, no, I, I, I, I, before I put the needle in the belly, I just thread the needle on the suture and hemostat the two ends together. 00, so it's, ah, so when you push the needle in and you pull, oh, I get it, and it doesn't, so let me try to see if I can explain that. Yeah, you have the, the suture through the needle in the process of pushing it down in. It's looping, um, because you, it's trailing, so when you push it in and you pull the needle out, now you have a loop, yes, and the needle doesn't cut the suture by doing that. No, it does not, and it's way easier. The other thing I was gonna add, so that's the way I've been doing it, but since I got back to Atlanta now, um, we actually have CK's all here. And I used it like you did way back when, and I was like, uh, didn't really add much. I think it actually is really nice coming over the vast, nicer than the needle. And you don't find it to be a pain. To re-thread that suture back in the hole laparoscopically. So I don't. I do this, I, I, I then put another suture through the other side the same way, loop it through and pull it out. I just do a suture loop. So I've, so I've loaded with a suture on the other side, so that I can pull it out the same way you do. And, and again, it saves a step. So you put the all in, yep, it makes a loop, yes, then you take the all out and you put it through the other side with a loop, with another suture, with another loop, yes, and you push it through the loop. Pull it up and it and it and it has enough length that it pulls it all the way out, yeah, the same way your technique does and you like it better than a needle because it dissects better, I think so. I, I've used it like 4 times, so I'm trying to see if I get used to it. You make a video. Those are, I would, I love the all also I would switch. Can you show me, make a video next time. You have to, and you can push, you're able to. 00, you grab it with a Maryland and pull, pull the loop through, yeah. OK. And then the other thing I think that you said, you, you mentioned that, you know, I think is important to emphasize is I, I hydro dissect, unlike CK and when I'm hydro dissecting, I always am very mindful of the hydro dissection over the vast because I think you put a bit, you put a couple cc's of marcaine there and that vast is gone. The peritoneum lifts right off. OK, I'm gonna answer that. First of all, keep trying to turn your camera cause I'm getting dizzy. Second thing is, I wanna respond to that. Everyone asks about it's keep just, you might have to probably just keep turning it, so. Everyone asks about that. Um, I don't, you might have to switch your camera, but here's the, here's the thing, I wanna make a comment about this. People say, when you hydro dissect, you lose the vase. Good. Good. If you don't see it, that's good. You don't need to see it. You just need to see the needle without a thing over it. So, I'm OK that you dissect the vase away. Do you disagree with that? I agree 100%. OK, wow, 100% agree. OK. Um, so, by the way, um, I, I think there were a lot of people, I love Mark that you're on here. Please join in, guys, if you have comments. Mindy, I know you had a lot of thoughts in your group there, would love to hear some of the experiences. Like I said, uh, literally, I, these are important. I hate that it's me by myself cause this is a group discussion to hear how people are doing it. Uh, Mark, I don't know if you can see some of these comments, you can help me here. Um, monofilament, um, is so much easier to work with, but I do not trust it for the repair, because of what we've seen, the pretty profound difference between abraded And a monofilament. And so go ahead, Mark. What I, I was gonna say, Todd, I, I don't know if it makes a difference in humans or not because I've used prolene. I've even used PDS cause I, I like the idea of having something absorbable. I wish there was a braided long-term absorbable suture, but Mark, how do you, how do you explain this? How do you explain that we know when you use a braided suture and cut it out? It stays scarred. But when you use a monofilament absorbable suture, It, it opens. It shouldn't, that shouldn't happen unless somehow the braided is what's causing this, the inflammation and the scarring. Well, I think you need to make sure you tie the suture tight because I think you wanna make a scar. Um, you know, the other thing that may save me that when I use PDS or monofilament is I burn like you do. I, I, I learned that from you. I burned the top half, uh, the crescent, and I think that's very important. And it makes scar. So, I, I, I don't know. I don't know unless we did some sort of randomized trial. I like the idea of something soft. You know, my biggest complaint that I've had, I've had a handful of patients that, they can feel the bump. Right, even, even after a year, no, I was gonna say, but I always tell him it goes away. It does go away as the kid gets bigger. Yeah, um. Mark, um, Uh, so everyone, Mark Wilkan was my boss at um Akron for a long time. Mark, I made the comment about, um, That I've never had someone come back to me with a recurrence. Do you think they're going to other hospitals? Like, where are these recurrences? It's OK. I took care of them all. I knew that's what I was getting at. Have you been taking care of my recurrences? Uh, no, you know, you know, Todd, uh, I, I, since I've been doing lap repairs. Uh, I have not had a recurrence either, you know, knock on wood, that came to you that I know of, that I know of, but I do think they come back. I mean, you know, you're a nice guy, Todd. People, you know, your patients love you, so they're gonna come back to you. Where, where I, you know, again, where I think this makes a difference, where I have had recurrences in the past are the premie open hernias. And I, I really think that this technique is a game changer for preemies. I love, yeah, Mark, there's a request for a video of your stuff, uh, and Doctor Gaffar, I can try to, I. I speak Mark, so I understand what he's saying. If you want, I could try to draw it out. But um, essentially, the idea is, if you singly thread a needle and push it through. Um, the, the needle, the thread as you push through sort of loops back on itself out through the, the tissue, so it makes a loop, but, but he'll make an, he'll, he'll make a video. He's good at making videos. Yeah, I'll make a video. I, I, I'll make a video Monday. OK, perfect. And, um, oh, perfect. Well, who do we got here? Hi Todd. Hey, how are you hello everyone. Thanks for joining. What's up? Yeah, good. How are you doing? Good, thank you. Yeah, I'm from Nepal, so great evening to all of you. You too. So, I just want to share, I have commented. So, we don't have, uh, Ehi bond available exclusively in Nepal. So what I'm, I've been doing is using the Prole stitch. So, uh, I, I use what Martin just said. So I use, uh, 22 gauge spinal needle, and, uh, single end is inserted through the needle, uh, making it a loop. So, I just, uh, insert it, keep the loop inside, and, uh, through the needle, uh, from the inner side or the medial side, I just pass it through and pull the loop. So, till now, so I have completed just over 600 cases. In the last 9 years. So only 2 recurrence in the first year. And, uh, both recurrence was seen within 3 months, and both were due to the faulty stitch itself. Uh, because like Nepal is a developing country, sometimes we get rebranded sutures. For example, the sutures that are expired in US or in Europe, they are sent to developing countries and rebranded as a new expiry date, and this prole was weaker than a cotton thread. So yeah, that shouldn't happen, yeah. So that was the only true recurrence case that I face till now. Uh, and, um, I wanna make sure I won't pronounce your name. It's Neresh, is that right? Nupresh, um, first of all, we have, uh, an organization that sends supplies all the time. We are never allowed to send anything that's close to expiring, so even if stuff is sent, it should never be expired. So that's terrible. The second thing is, um, I think use whatever stitch you're using if it's working. Great. CK still uses the monofilm and prolene. So, um, we just found that the knot is bigger and it's a softer knot with, with a braided, uh, and, and, and, and we think braided works. But if, if that's what you have, congratulations to you for so many cases with such great results, and, um, it's a shame that you're getting expired, um, suture. Yeah, so not now. So I always check, uh, the strength of the suture before passing it as a loop, just as a precaution. That's a great idea, great idea. Yeah, um, so thank you, thanks for joining. Thank you. It's great to see you. Thank you. Yeah, see you. Bye. See you. Bye bye. Um, again, in the last few minutes, um, happy to answer any questions if others have them. I know that there's a million questions written here. Um, Gabriel, please, you know, welcome to call in, Mindy. Um, do a single, do, um, one needle will be with loop and the other needle with a loop needle. Yeah, yeah, yeah, yeah. Uh, do a, uh, Fuhuanhuang. If I don't have 22 needles, I just use an 18 gauge IV cannula. Interesting, yep. It's amazing how everyone kind of does their own thing, um. A um. Again, questions. Mark, do you know about the Banks or Ferguson techniques? I don't, I don't, I'll look that up, uh. Um, oh, hi there. Hey, Doctor Kafar, how are you? Good. I, uh, I saw a couple of questions that I'm not sure you answered. One was, um, someone is wanting to learn the technique and wondering the number to become proficient. Great question. Here's my thoughts. I'll hear what Mark says or anyone else. Um, it is as easy as of a technique there is. If I'm doing it, it's gotta be easy. Here's the deal though, um, What I will tell you is, even though it's easy, it's not so intuitive, the first time you're doing it. And, uh, you know, we'll do, uh, you know, complex esophageal resia repairs, thoracoscopically and lung resections, and then we'll do a hernia repair, and they're struggling more with that than the, the MIS stuff, the, the neonatal stuff. I think, um, I think that what I would recommend is Have a way that you're with, are you in practice by yourself or are you with uh a team? This is someone who's a trainee who asked this question. I got it. Um, if it's a trainee, like, I usually let, make them watch me a bunch first, then they do it with me there, and it almost always requires correction for the first bunch, and then they eventually get the hang of it, but it does take quite a bit of practice, and um I recommend that if you're in practice by yourself, try to spend a day or two with someone who does them. Um, or have someone come to your hospital when you're doing, uh, you can line up a day of hernias. And that's like the easiest thing. You can't line up a TEF repair, but you can line up a day of hernias and you can do them with someone. I, I don't have a number, um, but I would say that Each time you do it, it gets easier and I, I, I would say, I don't know, 5 or 10. Mark, what's your answer? Yeah, I was gonna say, it's one of those things that when you first do it, especially when you're pulling that suture through, and sort of understanding how that works, but then once you see it a couple of times, it's like, oh, then it becomes intuitive. I really think if you, if you watch 2 or 3, and then do 5, do, you know, 3 or 4 or 5, you're gonna be fine. I, I think so, yeah. Great. Another question was, um, for orchiopexy, are you doing anything about the opening? No, no, I leave it. Mark D2. I, I, I leave it. Yeah, OK. I feel like that's a popular answer, um, and then the other thing for girl Bernie as people were talking about suturing, and I've also just wanted to throw out there endo loop could be used as well if you wanted to do some sort of suture reinforcement. Absolutely, yeah, so Todd, I'm sorry, I, I don't, I don't suture when I do Barneyio. Yeah, and I've done unless it's a really big hernia, and you know, uh, Jorge Godal, who, who, you know, Godoy, yeah, yeah, Godo Jorge Godoy developed the technique and he had, you know, and he's a Has, I don't think he has, he claims he has no recurrences, and I believe him. I mean, he's a straight, he's a straight up guy. uh, and I also think it's a great technique for girls when you see, you know, when they have the patent prosthesis on the other side, it's also, you can just burn it and, and be done. Yeah, no, you're right, I I could be, I I'm just, it's boot, it's, what is it, belt and suspenders, it's just an extra thing, but you're right, you don't need to probably. And then, um, sometimes when I was trying the bernia, I was having some trouble like getting the sack fully inverted. Do you have any tips or tricks for that? Cause it keeps just like kind of flipping out of my graspers or not fully inverting or inverting into the abdomen. I, I agree. Um, two thoughts on that. Here's my concern with bernia. If you do not have a good inversion, inversion of the sac. I get worried you're gonna keep cauterizing and cauterizing and cauterizing, and it could cause external damage. Uh, so, if it's not a good 1 to 1, like tight pull and you've got the thing there and it just destroys it quickly, if you're finding you're burning for more than a few seconds. I, I, I wouldn't do it, or I would just, I would switch to the percutaneous and just use your cautery as the injury and stitch it. Because sometimes it doesn't invert as easily as that video shows. Right. I mean eventually I got it, but it took a bit of pulling, yeah, yeah, and it did burn quickly like you said, so it wasn't, it wasn't that issue. The issue was just getting it to do theversion. Yep. Yeah, I, I work, Todd, I agree with you because I think that if you get too aggressive with that, you can burn the ileo inguinal nerve and possible cause inguinaldynia, and like you said, I think burnia hurts. It's not, it's not pain-free. You still need to inject. Exactly, exactly. Um, Any other, yeah. OK, so for muscle defects. Do you think so there's tap and tap and open, right? Do you think That there will be more adult surgeons who are high ligation for Indirect hernias. Or that there'll be more ped surgeons who come out knowing tap tap to help like with multiple, you know, multiple surgery issues. Here's the question. Junior surgeons that freshly graduate from general surgery really know how to do a tap and tap, but we do them so infrequently that it could be a decade before you do it again. And so, um, my concern is only those who have just freshly graduated will have really good experience now. Um, who is it, um, uh, Aaron Lipscar from, uh, in New York says that he, he does those quite a bit and he feels comfortable. I don't cause I haven't done it in a while. Um, so I think that there will probably still be the divide because of what we're comfortable with, who we see a lot. I do think you will start finding more adult surgeons getting requests from patients to have a non-mesh lap hernia repair. Mhm. Well, we are here for them, so yeah, absolutely. Um, it's all the questions I got. Awesome. Well, thank you, and it's a good, good suggestion. I'll send out like a list of all the key things we talked about. Um, there were two more questions other people put up. Victor, um, says, curious how the painters after Bernia. What is it? He's curious about what the pain rates are after a burnia, Mark, I, I, that's why I think if you do a lot of burning, it hurts. I think if you do, if you can do that tight, quick burn, it's, it's much better. Mark, I agree, but I still, I still, I still do the, I still do almost, I wouldn't say I don't do hydro dissection, but afterwards, I'll still inject because I think that we can do a really nice ileoanginal nerve block. When we're looking from the inside, if you inject just lateral to the defect. And I think that helps. Um, Uh, are there, I, are there other people on stage that wanna talk or no? I just saw someone pop up. Um, I'm not sure if Doctor Tufa would like to join. Um, that's fine. I, I didn't know my, so, um. Eliana, were there, was there another question that you were reading? Um, yes, there is another one. Someone. Had questioned about doing a hydrocele repair, like a very large hydro, OK, they said, Mohammad Al-Rafai, how do you operate on a very large hydrocele tested through an intraabdominal lapper open? Uh, so, uh, I, I do those laparoscopically. Um, if they're very large, it's even, that's even more of a reason to do those laparoscopically. Sometimes they can go all the way up and, uh, those, those are a great lap approach. You know, Mark started in the beginning about iPad. It's good to join that and have a network of people to call, like, uh, I, the, the way I think that I was able to be able to do all the different procedures I know how to do is because of Mark can tell you, I'm not afraid to call people and say, hey, Come, come show me how you do it. You know, I feel like we always have to think that, that we should be exploring with each other to get better. I feel like, um, I may think I do it great, but I want someone to, to show me, and, and it's such a great community in our field of pediatric surgery. We're all so excited to go to each other's hospitals and show, and everyone's willing to do that. So, I would recommend, if you have a case like that, a huge intraabdominal, um, Hydroseal, that, that is a great case to call someone and come do it with you. Um, so, I, I think, um, I think that's it. If there's, are there other questions? I don't know if um. I might see one more. OK, uh, Tariq Sara said when to do a lab myopectomial repair and a congenital inguinal hernia. Did we answer that? When to do a what? Uh, laparoscopic myoppectoneal repair and congenital inguinal hernia. Yeah, so I don't, I, I only do the peritoneum. I don't feel like I know how to do a Cooper repair or a McVeigh. I can't do those laparoscopically, um, with just, I don't, I don't know how. I'm sure that will be the next phase. People keep asking what's the next, maybe that's it. is a, a more sophisticated approach to the lab repair where we can actually identify. The, uh, you know, different landmarks and do muscle repairs, do, do mesh repair laparoscopically. I just don't know how to do that right now. Um, Mark. Yeah, I, you, you know, Todd, I think you can. So for femoral hernias I've done, you know, I've basically done a, you know, Cooper's ligament repair. You can get to Cooper's ligament really easily, and it's nice, and the, the, and the anatomy is really beautiful. So I think it's, it's possible. All that being said, I, I don't know that we, we don't need to, right? This high ligation. Is just as good if not better. And look, if, if I get a hernia, even at my age, Todd, and if it's an indirect hernia, I want you to fix it using this technique, right? Because you don't want mesh and then. And those other hernia repairs hurt. And I believe those other hernia repairs lead to, you know, the recurrence rates, when you start messing with the floor, goes through the roof, then you end up with, you know, over 1% recurrence rates, 2 to 3% recurrence rates. And so I think that this really is the best hernia repair that we have right now. So the only argument, um, and by the way, I know our time is over and I'm happy to keep going over some of these questions. Um, the only comment I'll make to those who have to leave is, um, please come to the update course, which is in a few months, a couple of months. Um. And come in person. It's really fun. Uh, we broadcast it, but it's really fun in person too, so, uh, we'll sign up for that. That's, that's where we just highlight all the big practice changes every, every year. Um, all right, so back to, um, Mark, let's say you had a hernia. As I showed in that graph, the chance of you having a direct is much higher. And to Iliana's point, Who do you want? Like, if I go in and I see a direct, I'm not gonna do a tap or a tap. I'm gonna do an open mesh repair, or I will come out and send you to an adult surgeon if that's, like what would, that's the only downside of us fixing adults. We have to be prepared for way more directs. Yeah, well, I don't know that it needs to be us. We need to teach the adult surgeons that this is the right way to go, just like the study you're doing in Norway. And for those of us, so maybe I wouldn't pick you since you're not comfortable with the dappert. I would go there to do it with them, which is what I did with Mike Rosen, yeah, yeah, because that's what I'd want you to do. And even still, remember, everybody forgets the most common hernia, even in old guys like me, is incorrect, yeah. Yeah. No, that's a great point. It should be, uh, we should be doing this with our adult colleagues where we go there with them. Um, hey, Debbie. Hi. So I wanted to clarify the point. Well, first of all, thank you for allowing me on stage. I'm Debbie. I'm a pediatric surgeon based out of Mexico City and Doctor Diffenbach's incoming MIS fellow for this academic year. Um, thank you. So this is my question. So, um, and sometimes I know you guys aren't used to eponyms, but I know you're gonna know what I'm asking. So. The Mitchell Banks technique is basically when you're doing on, uh, smaller babies, when you're doing an open hernia repair, and because the baby's so little that, uh, the inguinal rings are almost superimposed, so you don't have to open the aponeurosis of the internal oblique. And you just do the repair. And I know that at least at home, uh, with most of the surgeons that I've operated, they like to do the Ferguson repair, which is basically another fancy name for the usual open repair where you, um, open the internal oblique aponeurosis and a little bit of the inguinal ring and do the repair. So my question was, what, in case you had to do an open repair due to lack of Uh, materials to do a lap repair, which technique would you prefer over the other, thinking that when you do the Ferguson repair and actually open the internal oblique aponeurosis, that could potentially, um, have a weaker, you know, aponeurosis, cause even if you open and repair it beautifully, it'll never have the same strength as, you know, not opening it, but that might, um, but that repair is sometimes easier and you could see the structures very clearly. So. What would your preference be if you had to be in that situation? Go ahead, Mark. Yeah, can I take this, Todd? Yeah, so, so, so Debbie, the, uh, external oblique aponeurosis provides no structure whatsoever to the angular floor and whatsoever. You, you, you don't have to worry about that. I actually, in preemie hernias, uh, I've done it both ways. I didn't know the eponyms for them. But, you know, I, I, because again, like you stated, in a tiny baby, the two rings almost overlap each other and you can dissect it out, and I do that all the time. You know, Walter Kane taught me how to do that. You put the hemostat down, you, you, you spread the creammasters, you close it, and you pull up and magic, you have the sack every time. It's awesome. And uh whether you open that or not, I open it if I need to, I don't if I don't. I don't think it makes a hill of beans worth the difference. It's actually a board question. They always have like the external bleak and the internal bleak do not offer strength. Um, they are, they are there. As a landmark, the reason you close it when you're done is so you can go back, if you have to go back in, you know where you are, uh, so you don't dive into the cord. It doesn't offer strength and rarely have to open the external bleak in a, in a, in a baby because it's just right there. Yeah, got it. Thank you. Thank you. Good luck next year. Congrats. Thank you. Yeah. Um, I, there was a question. Do I use the barb suture? Um, I have tried it. Uh, I don't use it routinely, Mark. I don't know if you use, it's certainly not for hernia repairs, um, but I've tried it, I think, on a Nissan, but I, I don't use them. Mark, no, I, I don't use it either. Yeah, um, uh, any other, I don't know, there's a lot of questions here. I know we didn't get them all. Um, tips for starting burn, I would just say. Uh, it's a great question. It depends on, I, I would always say if you have a colleague, do them with them. If not, schedule a full day of, go, go to watch someone do it, then have them come there for a full day of hernias. And, uh, and that, there's usually, there's plenty of people that would, that would be happy to, to come do that. Um, so, um, and I'm volunteering, Mark. He's, he's always willing. So, uh, I think that's it. I think we've answered everything. Um, if there's questions we didn't answer, please email me. Um, I really wanna thank Aya, Kiki, everyone, uh, Carolyn for, for putting this together. Um, we, seems like we keep doing these, uh, which I keep thinking no one's gonna wanna hear this anymore, but it seems like this is still something people wanna hear. Um, so we'll keep doing them. Um, and, uh, I really appreciate everyone being so interactive and giving a lot of, uh, new information. Um, again, um, please come to the update course. This, um, this will be, uh, recorded and we'll make it available. Uh, but, uh, uh, thank you, everybody. Um, so, with that, uh, good morning, good afternoon, good evening, and we'll see you next time. Thank you.