Focus on Technique- Laparoscopic Pediatric Hernia Repair 2015

And their recurrence rates were equivalent to Ziggy Es, which is like 1.3%. So that's when it first, and the crazy thing was that I remember listening to realize the value of this is that we were like, that is crazy. You know why I hate the sack? And so I pulled the audience. But then I was like, who, who's heard of doing that? Sure, it's finishing. Generally Military service. Hey, that's surprise. Yes, he's a joking that last night was, oh, there's an echo somewhere. The, the, uh, last night the show we did all the faculty were from like Daytona and like all these places I'm like, oh thank you for coming to the tour center of the United States Akron, Ohio. Um, listen, I thought of something. I don't know if you guys are. But if, uh, freak you out, but if you want, if you're still here at the end, you can go get a beer and pound through sample cases if you wanna do. Or is that, would that freak you out? It would freak you out with just an offer, just an offer. I've been telling Aaron that because that helped me because someone did it, um, or you just do it on your own. You know, just let me know if you guys wanna do that. No, that would be, that would be, yeah, my pleasure. And, and I, and, and I actually won't know the answers, but I at least can tell you the cases that I have you ever been an examiner? No, no, I'm too junior. They don't want me. I don't know anything. It really restricts you, I guess, in years because they. Is that true? Oh, maybe that's yeah. So I mean if you're too young, maybe I don't know, yeah, right, yeah, it's 5 years. Um, that's a shame. Wait, did you guys go to the DC course last year? Oh, OK. That's when I met you guys. I knew because I met you, so they're doing it again. The next one is. Oh no, OK, so it's July, July, right. You're gonna do another one of those uh. Contemporary management, did, did you guys like that? Do you wanna do that part one? We, we're gonna do it in September. We wanted, yeah, we're gonna do it in September. Did you like the format? Or would you change it? Would you like more time on each topic or and less topics, like maybe do 4 topics for the whole day or do it the way we did, which was 8 topics, 45 minutes. people In the topic to monitor. Got it. So keep it focused like we did, OK. You also have this ugly guy. Did you get any sleep last night? Did you operate after the, did you get the battery? What did you use? OK. This came up with uh, sorry for the uh virtual audience we're talking about uh do you go after batteries? The question was, would you go after a battery in the stomach, and I'm like raising my hand and everyone else was like, no, I was like, you don't put my hand down. Well, that algorithm, right? They said not to, right? I. Right, it would have been there for 5 days, so. OK, sorry. All right, everybody, uh. Good morning, uh, good afternoon or good evening wherever you're located. I know you're coming from all over the world actually. Uh, I see Doctor Haida there from Bahrain, so welcome and thank you for joining us and many other people from all over. I know we got a lot of Europeans, so thank you, uh, for joining us. And this is, uh, for those of you who have, um, been a part of these events. I know we just did one last night, uh. And it was much more formal. This is not that way. This is Uh, discussion. Um, I have a brief, uh, Talk, going over things, and then we'll open it up for discussion. And then for the, for the few people that are here at the hospital, I have a full day of cases where we're gonna go through for the virtual audience. Uh, you will not be able to see those cases. So the show will end in just 2 hours. And then the rest of it's gonna be just uh cases here locally at Akron Children's. So, um, I really want to encourage everyone to disagree with what I'm saying because I'm not here to, to, to preach the gospel. This is here to sort of hammer things out and talk about what I do, what other people do, and sort of get to the, to the, to the bottom of, of, of uh what we should be doing with hernias and is there any role for it. So, um, This is the traditional open high ligation. And um, Just from the poll here, it looks like about half of the people here do uh the open repair. And, uh, you know, Aaron, you, you're mixing it in sort of considering getting into the lab, which is sort of here as well. And then Arturo, do you, do you ever do opens or do you do all your hernias laparoscopically? Mostly not, but, but you'll occasionally do an open hernia. I would, uh, always dance. your parents. Yeah. Yeah. And that's exactly me too. If they, uh, you know, if they're not interested in, you know, they say we want the more tried and true one that's been around for years, perfect. I don't push them at all. I, I say whatever you want. Um, and we should talk about that, you know, what, what we guide parents, what I tell them, even though we can get that at the end, I'll just say it now. I say, I explained to them that both options are great. There's some advantages to each. Um, although the advantages aren't. drastic. So I'm fine with either procedure. Um, and then based on who the patient is, I tell them what I would recommend. Usually, it is laparoscopic. Um, um, and I tell them that With the, the recurrence rate, in my opinion, from what the more recent studies show is about equivalent. And so that's, I was, you know, it's funny, the adult hernia surgeons yesterday were all talking about pain is their big concern and infection. That's not really what we care about. It's really just recurrence. Um, and so, uh, I, I, I think that um I tell them that it's a newer procedure. It has not been around nearly as long as the open approach. So I can't tell them the long-term results. It may not be as good. We may find out years later that the lapse are recurring. Although you'll see why I think that it would be the opposite. Um. An interesting reason why I think lap will have a lower recurrence in the long term. And for the virtual audience, please feel free to go ahead and type your questions, and we'll try to address these. So, why do the open approach? So, it's the tried and true method. Um, it has a low occurrence rate, low complication rate. Small scars are usually hidden. In the lap repair, the sac is not removed except the way Arturo does it, which we're going to talk about. But for most most uh techniques, it is not removed. The laparoscopic repair may need to rely on a stitch to keep this thing closed for their entire life, which is a little scary to some people that you're hoping that stitch lasts forever. Um, The laparoscopic repair takes an extraperitoneal operation and makes it intraperitoneal. Um, and so a lot of people have a problem with that too. And there's discussion of cost, uh, which to be honest with you, we don't really get into that discussion so much because I don't, I should probably study it, but it doesn't seem to be much of a difference in cost. Once you have the established fixed cost of laparoscopy, you're not adding much. Um, and, and if you're using just one trocar at the most, then you probably really aren't adding much cost. So here's the argument for the laparoscopic approach. Now, With laparoscopy, always it's cosmesis, right? Lab, it's cosmetically better and everyone's like, you know, a lot of these papers that are out there, they always go into cosmesis. And is cosmesis an argument for laparoscopy? Those are my, this is a bilateral hernia repair, and you can see the scars are pretty tiny. I think that's the yellow scar. So they're pretty small. So is that an argument? No, because if you look at an open hernia repair, there's no scar. Because it's hidden in the underwear, so only those who are very close to the man or woman, when they're older, will see that scar. So I, I do not think that cosmesis is at all an argument for the laparoscopic repair. In fact, you could argue that it's worse cosmetically because you, you might see those little dots above the in the abdomen. Um, so I, that's not an argument. The argument for, let's talk about other arguments for the laparoscopic approach and we're going to get into these in detail. It may be easier, and by the way, interrupt me if I'm talking, you have a question. Don't be polite. It may be easier and safer for the challenging cases. That's what I think is the main reason for this. For a case, if it, if you're ever doing a hernia that makes you sweat, you shouldn't be sweating for a hernia because laparoscopic is always pretty easy. I just totally jinxed myself because I have 5 cases today. I'm going to be sweating. Um, so, And, and I'll tell you something interesting. I was talking to another surgeon, another hospital that does almost exclusively laparoscopy, and they were saying that the new surgeons that are coming out. Us, you know, are going to be so much less well trained in the open hernia. They did it in fellowship, but if you're doing laparoscopy, I rarely do open hernias anymore. So it's interesting you've become more comfortable with lab than than open. Um It potentially eliminates the most common cause of recurrence. I'm going to leave it, leave the uh the uh question mark there so you'll find out what it is later, why I say that. It may be less painful. And I think this is most true in the case that Aaron asked me about yesterday in the adolescence. I think in an adolescent, you have to make a pretty sizable incision. You're doing a lot of messing around in there and probably one of the most innervated parts of the body and versus a percutaneous stick. I think that pain is going to be substantially less in this operation. Everything I'm going to keep saying, I think, because until I do my data, it's all speculation. Uh Maybe less traumatic for the cord structures. We'll talk about this, Arturo, but I, I think, and again, unless we wait 50 years from now, we're not going to know. Everything is speculation. I think theoretically, it should be less traumatic for the cord structures. Allows for bilateral evaluation. Now, for those of you who do open hernias, do you do lap works? Do you do lap work? OK. OK. You do. OK. And just out of curiosity, just for Um, for, uh, pass this around to the area just for technique standpoint, do you, um, Do you put a trocar in through the sack. You just put the scope directly into that. You put a, how do you insufflate? What do you do? Yeah, so my partner puts a red rubber catheter in through that and then put the 4 millimeter 7 scope straight through the sack. I was trained to put a 5 millimeter mini without this, without the just the sleeve on it. Oh, without the sleeve, the sleeve through the sack and scope. And you use like a 70 degree scope. And do you think you can see pretty well coming from the side? I can, but you know, this year someone came and I fixed a hernia that my partner had done a lab look 3 years ago and there was no hernia, so. You know, I think, I don't, I don't stress out to do it. If it's hard to do, I really just pick that one side, the one side, OK. Do you? You do, OK. Oh yeah, sorry, it's my fault. If it's a, you know, a really thin sack and I can't easily get in there and I don't OK, and I really after 6 years they really don't. Unless the patients have under 6. I, yeah, I don't know why I came up with 6. I felt like at first I was thinking 2 is, you know, that's really when the highest rate of, uh, pain processes on the other side is. But then Is that true? 2 years of age is the highest. That's what I found. Oh, interesting. I was doing, I didn't know, but. And then, um, I decided 6 years was a good, good cut off. I think we talked about it and you know, with that and sounded pretty good, but then in the old sometimes the older kids might have, oh yeah, it kind of hurts on the other side. So then I would, yeah, for sure. Have you ever, has anyone, because I haven't seen this, but I know this is always a theoretical concern. Let you copy that, um, the, um. About hurting the sack by manipulating it. Has that ever happened to anyone here? Ever seen it happen, tearing the sack? No. OK. Well, according to you, that's the discussion we had, it just shouldn't matter. Let's now about that. I tore the sack. I'm like, I guess. That's right. I, I actually agree with that. Yeah, go ahead. When I do do open, um, I do look to the other side, but, uh, younger kids haven't, haven't come up with a firm age yet. It's interesting so far. OK, you too. The ones that we do, we don't really one side good. OK, good. So we have a good split then. And then Arturo for your opens, do you lap look? You don't do opens, OK. That look, OK. And I'll also do the trocar. We have a 120 degree angle. Is that right? The endo endo chameleon, or is it just a real, it's really angled 100 yes. Occult and then we also increase the insulin plate. OK, open it up. That's a good idea. Small percentage, it's actually reasonable percentage and Rothenberg talks about what he did when I was, he, he does this still, I think, is that he puts a um an angio cath directly on that side and puts a 1 millimeter scope into the angio cath. The problem with that is the 1 millimeter scopes usually lasts for about a week in the hospital before they're broken. So, uh, that's um Do you wanna sit down? Oh, you do? OK. Um, so, uh, that's interesting. So, so my thought on that is, um, This is kind of crass, but so my, my old partner used to say a quote to me. He said, Why eat tomorrow's lunch today? So, um, we just, I, I don't go look at the, on the other side. If I was doing it. I just do the one side, but I think anesthesia risk is so minimal today that I don't do it, but it's, there's no right answer. Um, OK. I'm curious. We talked about the tiny little flap things. If you go in, Arturo, and you do laparoscopy for your hernia and you see a little tiny hole like this on the other side, do you fix that? Like a little pinhole hernia? You will. Yes. OK. OK, good. So, um And then same operation for any age, and that's another exciting thing we'll talk about at the end. Yeah, question one. So let's first talk about easier and safer for challenging cases. So the giant preemie hernia. So, you know, it's been stuck there. Usually, it's scarred. There's a peel. Um, the sack is so friable. Um, I think that this is such an easy case laparoscopically. It's no harder than, than a bigger thing. So, um, and interestingly, for those who have reported recurrences, um, including myself, um, I don't know anyone that has had a premie recurrence. It's very interesting, and I don't know why. Um, I don't know the reason why, but for some reason, no one has. It's the older kids that would get recurrence. So, uh, maybe their tissue heals better or scars better or whatever it is, but I, I have not, I mean, again, jinx myself, but that's a rare thing. Um, incarceration, uh, is it, yeah, right, so that would be why, um, sometimes you do these open, right? So I will try if they tell me you know it's a cardiac kid and they don't have the power and circulation, then I'll tell you what I do for those. I do them laparoscopically, but I do your technique, uh, which I'll explain because it's so fast, the seal. so fast and I can just do it in like a second. Um, so I'll do that or I'll just do it open, but I see, I think that fear, uh, isn't as bad as people say. It's rare to me if, if it, there's cases where general anesthesia. hernia, but if you're no anesthesia, I think most of the babies tolerate it. Have you done that? I have. Wow. The strap them down. Get a good spinal you know time starts in you. Wow, that's great. Have you? Oh, we have, uh, so we have a question. From the virtual audience. Ah, we have good questions being asked. And in fact, this was on this, this great internal, there's a great Facebook hernia thing with it's one of the biggest medical Facebook things. hundreds of people and people ask questions about hernias, and one of them asked the same question about what do we do with the round ligament. So let's just do it. Um, what do you guys, how do you manage the round ligament if you're doing a girl? Do you divide it or do you leave it alone? you you just like it the sack either or, OK, so you don't, it's not a big deal either way, yeah, OK, OK. I do all the girls with the version. Um, you do that twist it, put 2 under 0 and I think the. We were just talking about that. So, so we'll talk about that. So, um, the answer is, is interesting. I got to look it up. I'll look it up if, if we ever get a break. But um I never cared about the round ligament until these adult hernia surgeons were telling me, you've got to be worried about, you can't just provide the round ligament because there was some Uh, problem with suspensory thing leading to something. I don't remember. I got to look it up. But they were saying you, you shouldn't divide the round ligament, which is news to me. I always thought I divide it. Um, so Uh, and then the other question was, um, Yeah, there's some people saying that they use a 70-degree scope and a 2 millimeter port. I used to put a little red rubber catheter, so I was taught insufflating sliding scope alongside the catheter. Um, So that's incarceration. Incarceration is a great opportunity. This is a great thing with laparoscopy. You can push and pull almost like an intussusception, um, laparoscopic anyone doing laparoscopic intussusception. OK. I just did one yesterday and was not able to reduce it laparoscopically. I tried and uh it was, it was a six year old child and it was dead gut. I had a resectomy radiologist. You know, I know someone who did an ene does that enemas on the table in the OR while he's doing it laparoscopically, um, yeah. Like, let's say you're pushing and pulling and you can't get it. I haven't had that happen yet, so it hasn't happened and I have not been able to reduce it, um. Um, what I now in resident general surgery or maybe it was in fellowship, I have done that and we did it. That wasn't open, wasn't laparoscopic, and we just, I just opened up the ring, right? That's what I would do. I would, you know, open the, um, in order to reduce it. So I was just wondering, could you. Do that laparoscopically. You could, I guess I would be afraid because I would be afraid that the hook would be touching the bow, but I'd have to see what it would look like. Maybe if I could, you could take scissors. Yeah, absolutely, you could, you could, um. Absolutely. You said you seen someone do that? Yeah, there you go. OK. Um, Let's keep going here. So a recurrent hernia. Um, this is a picture from the internet, so I don't know. It looks like it's a pulling or something. Uh, but, uh, you know, that's another reason for the laparoscopic. It's another reason for the laparoscopic approach. Because a recurrent hernia is actually quite easy to fix laparoscopically. Whereas it's a really, real challenge open. Uh, it's a, uh, you guys can't see. All right, let me know. Yeah. You can look at my screen. You look at mine. Um, So this was actually one of the first reasons why we had talked about doing lap hernias just because the recurrent hernia can be a real challenge and uh putting the vas and vessels at risk. And I think that doing it laparoscopically, it's Very, very easy. Um, Next is potentially eliminates the most common cause of recurrence. Now, this is speculation and I don't know if Jeff DuBois is on here yet, but he and I have been going back and forth. Um, I presented this in Denver a few weeks ago and he has been sending me some emails about the conceptual Mic argument here. He has some, some issues with my argument. And here it is. When you look at a recurrent hernia, this was a case that I had uh earlier in the year. It was a, a, a recurrence from a hernia from a surgeon, a very good surgeon who didn't, does open repair. And I went in expecting to, to find recurrent ininal hernia, but it wasn't an indirect, it was actually a direct. OK. Now, believe it or not, that may be the most common cause of recurrence. OK. When you look at all comers of, of recurrent pediatric hernias, it's, it's some studies, the Mayo Clinic study more often direct. An indirect. OK, that's interesting. And when you look at the adult hernia surgeons and say, oh, we're fixing your pediatric occurrences, they're finding that they're direct hernias, not indirect. So, and then Grossfeld found 30%. Certainly a substantial number of occurrences are direct. What is, what does that mean? I mean, I can think of two possibilities of why. One is that we're misdiagnosing these at the time that we're doing an indirect. We just always assume sack closed, good night, have a good day, or we're screwing up the floor. And I think that damaging the floor is a very likely possibility in these tiny preemies that have a floor that you can see through, uh, that when you're going and you're delivering up the cord structures very easily hurting the floor. And that's what I think. Jeff disagrees with me. Jeff thinks that it's, these are misdiagnosed direct hernias. In any case, both of these problems are eliminated with laparoscopy. You're gonna see if it's a direct or an indirect, and you're also not gonna screw up the floor. You can't. OK? So, uh, if we're making the argument that the most common cause of recurrence is a direct recurrence, and we are going to eliminate the most common cause of recurrence, the long-term results may actually be better for laparoscopy than open. Just a theoretical argument out there, OK. No, I want to talk about this. And I, I'm curious from people from the audience, um, Uh, and then David, I'll get to your question about the risk of recurrence. Um, it really depends. We're gonna get into that. Um. If you have a chance, tell me some of these questions too, and I'll try to get to them, but um Before I get to the recurrence questions, The question is, what do you do if you go in laparoscopically or, you know, if I go in laparoscopically and I find a direct hernia, I open, OK. I am not good yet at fixing a direct hernia laparoscopically. Here are my choices. I can put mesh in in a tiny little baby. I can try to laparoscopically do a primary repair, which I think I would suck at. I don't think I would be very good at doing that. Um Or I open and, and, and just repair it. Now, at the American College of Surgeons this year, I'm trying to think of uh who presented it. And if someone out there knows, let me know. They, they presented, it was a group that presented taking the, the round, the, the median umbilical fold and laying it over the direct hernia. And I said, that's a beautiful operation, but I can tell you they will be recurring because you cannot just lay fat on top of a direct hernia muscle problem. Now, their argument might be, how is that different than it's a biologic, it's like putting a biologic patch there, like putting surgesis or something, but I think that would fail too. We'd know that biologics don't bridge holes in muscle. They will be a temporary fix. So I'm curious uh if anyone else here would do something different. Anyone in the audience here, in the virtual audience, if they would ever attempt a laparoscopic repair for a direct hernia. I also think pediatric surgeons aren't very good at laparoscopic mesh repairs. Let's say it was a 17 year old. I mean, how often do we do that? I don't think we do them enough. I don't do them enough that I feel I would do a good operation for a lap. Uh, Yeah. I may, I'm wondering if I see a, a huge direct. I might try to repair primarily or I would just, maybe, I mean, it's never happened. Would I potentially send it to an adult surgeon who does mesh repairs? I don't know. I probably would just try to fix it, muscle repair. Any other disagreements with that? mesh in little babies. It's crazy. If it's an adolescent, they think that a mesh repair laparoscopic repair the repair. Who says I'm sorry, I think if it's a baby, the idea of putting mesh is correct. But for an adolescent 16 or 17 year old, it's very reasonable. Isn't it true? So what I was at the SAGEs laparoscopic course and the lap hernia course for adults, and they were saying that um That the data shows that the laparoscopic inguinal hernia repair isn't better than the open repair, not better. Yeah, so. Um, yeah, Adrian's got a question. Adrian, tell us where you're from, by the way. So chatting there, I'm curious where you're from. Adrian says, uh, um, and this is Dr. Kerno, in 26 years and 2500 hernias, holy cow, I've seen two direct hernias. I agree that we screw up the floor at the first surgery. I do a modified Bassini repair on all clinical hernias except after puberty, and then I do a modified should ice repair. Um, and he's from Boise, Idaho. So, um, Mark, we don't have the capability for them to call in, do we? Yeah, and, um, you know, if anyone wants to call in from the virtual audience and talk, you're welcome to. We'll see if we can get that. A voice over IP. Oh, so if someone wants to, uh, just talk, you're welcome to just uh click on the microphone at the top of the screen there. Um. So, Adrian, I, I, you know, that's the point that Jeff Dubois is making is that, you know, we don't really know what the story is with these, but when I talk to the adult surgeons, that's what they're telling me. And when they see our recurrences, they're directs. Um, And then there was someone here that says both of my, this is Christine White. Can you go ahead. I don't hear anything. Both of, so, uh, Christine White says both of my recurrencences were in preemies with large defects in pulmonary disease, but also before thermal scoring, yeah, before thermal scoring at site. All right, uh, Adrian, can you hear us? Go ahead, tell us your thoughts on this. Um, boy. Um I'm just starting on the laparoscopic. I went to, I went, I went up to Spokane with Keith Json back last May, and I've only done probably about 20 now. And, uh, I just share all the, I, I think everything that you're bringing forward is what I'm interested in because I've had 2 recurrences out of 20. And I had 3 recurrences out of 2000 plus before. So I just was like, Am I doing the right thing and I want to learn all the caveats that you have about microscopic. Uh, I wish I was there. My daughter had surgery last week and so I had to go to the, uh, just go to this conference online because I was gonna be Adrian this morning. I appreciate your comments and actually, uh, if you ever want to come here just by yourself one day, we can line up a day of hernias. There's no problem. Um, so I'm sorry to hear about your daughter, but, um, We're glad you're here virtually. So um I, I will go through and talk about what are some ways I think to minimize recurrence. At least we've definitely proven that at least in the animal model, whether it translates to humans, I don't know. Um. So are we causing a drug her or are we misdiagnosing? This is what I always show. This is like a big adolescent hernia, but you can see how you could potentially injure the floor. Um, so this is answering the question that was listed about what is the recurrence rates. Um, it really varies. If you look at who the pioneer of laparoscopic inguinal hernia repair was, it was Felix Sheer. But Felix Shear's original recurrence rate was 6%. And his more recent data is 3%. Now, I think I know why. Felix Shear is one of the most brilliant surgeons and really can be credited for coming up with this concept, but I don't agree with the way he does it. Um, he basically does a Z stitch. He goes in, he goes out, does it, and that's it, and then pulls it together. And I don't think that type of repair percutaneously is enough to keep this closed. So I think that's why he sees high recurrences. Um. Craig Albanese and San Sanjeev Dutta reported 1.5% recurrence of their seal repair, um, which we'll talk about, and Endo, uh, who's also one of the pioneers, had a 0.2%. CK Young, who's done well over 2000 as well laparoscopically, hasn't published yet, but tells that he's had one or two recurrences in that. So he has a really low recurrence rate too. So we'll talk about what I think are the reasons. Maybe less painful. Um, by the way, if someone wants to call in in the chat, just chat and tell us you want to call in and we'll turn on the speaker so we can hear you. Um, so, the, the, um, the hernia repair is obviously done in the groin where there is a lot of nerves. This is one of the most highly innervated parts of the, uh, body and, um, When you're talking about a tiny little baby hernia where you're making a one little tiny incision, that's probably not such a big deal. But I think in an adolescent when you're making a reasonable sized incision, I do think it hurts. And interestingly, last night when we did this adult hernia conversation, pain was by far the most common concern that they had. So it is an issue. Um, maybe less traumatic for the chord structure. This is speculation, and I admit it. This is speculation, but this is what scares me, the cord manipulation. And um, We know that in the rabbit, if you just grab the vase with the pickups and you look at it, it's obliterated. OK, that's how it's fragile. So in tiny preemies, when we're pulling this tight sack that's stuck to it off the vase and we're stretching it apart and you're getting down and you're separating the cord structures, I absolutely think we're causing a traction injury on the vase, and I, I'm having a very hard time figuring out how to prove that. And I asked the 13-year-old to give me a semen analysis, that's going to be tough to convince the parents to let them do that. So I Yeah, they do. If we could just give it to them a cup at home. But, uh, that, that's gonna be the study to figure it out. But we actually do have some data, and I, I don't know that the way to know this because it would have to be a bilateral hernia repair to show that there's really a problem. Um, because in the laparoscopic period you don't touch it. So infertility is in Dejas's study, 50-year follow-up. This is the big study. It's the only 50-year follow-up study that I'm aware of where they looked at, uh, at the Mayo Clinic. 213 patients, 5% were infertile. Exactly. So the, the point is, so what, what, what's the infertility rate of the general population? It may be 5%. I think it is around 5%. So I don't think it shows much of a difference. However, this study by Javetz had 8500 patients in a fertility clinic. 6% of them had a hernioplasty. Is that higher than the general population? No, I think about 6% of the general population has hernia. So again, we're not seeing a difference. The only thing he saw was for sure that when they looked at the semen quality of those who had a hernia repair, they had markedly reduced quality of the semen. Now, does that have any clinical significance? Maybe not. You know, so maybe this is a, a, a, a, a tree that I shouldn't be barking on because I'm not sure it really makes a difference. But it's, I bet if you could separate off the preemie hernia repairs, I think you would probably find some cord injuries that we're not. Lots of bilateral evaluation, but you guys are doing it anyways. And um there's a lot of, there's basically the way I divide the techniques is intro and extra corporeal or percutaneous versus pure uh intracorporeal techniques. So CK Young presented this, and I have to tell you, If I didn't do the way I do it, I would do it CK Young's way. And I, I've tried it. It's a little more technically challenging, and I'll show you why. Um, and, but it really looks like a good technique. And I think a lot of people like it. Um, oh yeah, can you play that video then, Mark? Oh, should I hit the play button? So CK here and um he, he has a needle that he developed and he pokes in, and here's the point that he makes. He pokes in in the groin and then this is uh an instrument that, that's a sharp or blunted tip, and he's passed a looped prowling through here. He's coming around preperitoneal here and um he is now gonna skip over the vessels. Very easily, actually. The vessels are easier to skip over than the vase for those of you who have tried this. You'll see me today probably struggle when I try to skip over the vase, and the vessels are usually very easy. Now here's the vase, actually, he's not having a hard time. He's going to get over the vase without a problem. Actually very easy There's the vase. He skips over that. No problem. Now, then he pokes out. Now, he takes the loop out of the hole here, so. Now it's. Now he takes it out. Now, the point that he makes is you can't come all the way out. You come out just through the peritoneum, but then pop in the exact same hole again. And then come around the other side. Now this is the part that's annoying for me when I was trying to do it. You have to hope that the tip of your thing is really crimped well enough to fit through the small hole. And it's a little painful, especially if you're having residents do it. Um And you, you do need to, you need another instrument, but I always use one now. I'll show you why. I, I added an extra instrument, not for the repair, but for something else. Uses a prole now. Watch. He also says that you have to pull this up, to pull the peritoneum down to get the suture directly at the internal ring. You have to get it at the internal ring. He thinks that's where the least amount of tension. That's what he says. Again. What we are dealing with is a very new procedure here, so everything is speculation. You're going to have to deal with that until we have good data. OK. This is the way that you do it. This is the way that you talked about. This is the Lil's technique. This is an this is an incarcerated hernia. In girls only. Yes, in girls. So this is incarcerated hernia. This is Scott Bollinger. He was my uh partner at Rainbow. One of the best, uh, laparoscopic surgeons that I know. And, uh, he's pushing from the outside with his fingers at the same time that he's doing it in. The great use of, uh, laparoscopy. Now, what he does, not anymore. He doesn't do this technique anymore, but he would reach in, grab, twist, or whatever. He twist and then you put the end of loop down. The critical part of this operation is we talked about before you came, that you mentioned that you do. you have to cut the sack now. If you don't cut the sack, it will recur because the loop will eventually fall off. OK, that's what people are finding. Pottery or scissors, the series that we wrote up when I was a research fellow at LIJ was like 180 of these, and the recurrence, the two recurrences were early before the recurrence. Interesting. So since she's cut this act, there was no, I believe that, yep, I believe it. OK. Um, this is the seal technique. This is the first technique that I, and I, I wanna thank Craig Albanese, who, who, and Matthias Bruzzoni will be on here later to show this in more detail. The guys at Stanford actually showed me this concept. I went out there. You're basically passing. Mark, can we pause it for a second? I want to explain here because this is hard to explain by watching the laparoscopic video. So, people can see me. Oh, let me, oh, cool, look at this. All right. OK Impromptu, uh So A series of skin. Here's the skin. Here is the ring. Take a big CT1 or CT3 needle, big, big honking noodle. On a regular needle driver, outside needle driver. And you pass the needle through the skin like you saw, and then you, you saw there laparoscopically, we're gonna, then you start seeing it come in. Here's the vessels, here's the vase, and you either skip, which is the way I was taught by them, but I think now they don't skip, they actually work their way between the peritoneum and the core structures. But the key point is you're still holding out here your needle. You're still holding your, your needle out here. And so you're driving this from the outside of the patient until the needle comes out here. OK. But you don't pull the needle all the way through the skin. You pull it so that the very end of the needle is still in the subcu. Here's the suture. Here's the needle. Here's the suture, and then you back the, the sledge, the sledge of the needle back through this right here. Now you have what it looks like is you'll have Sorry. We'll have the suture coming here around. And this, you can tie the whole thing down. That's the seal approach. It is by far the easiest technique out there. I don't like it, and I'll tell you why I don't like it. I used it for my first two years doing lap hernias and I switched because I think the patients had a lot of hernia. Um, you know, you know. OK. And a lot of people that are doing this say you're crazy. I have not had any complaints of pain. Um, I think you're getting I think you're getting the, the nerve, I think you could have the potential for getting nerve entrapment when you're doing this technique because you're getting all this stuff up here. I don't know. Maybe I was doing it wrong. I also had, I also had one for sure and maybe two recurrences in my first two years, and that was kind of high recurrence rate for me. So I, I Abandoned it and it might have been a premature, but I still do it sometimes. I just did one last week, so I still think there's a role for it, but it's not my primary. Yeah, I tell my resident. That to just be right under the skin, but we look on the, on the screen and we try to come as close as possible to the anterior portion of the ring. We try to minimize the amount of tissue for the next stitch, and we had a couple of references like you mentioned. And so what we change now is we, um, we do the first pass where we come in, interrupted to skip over the vessels, then we pull a little bit, and that allows us to hydro dissect a little bit, OK, we do a second. Oh, someone else told me this is the same, the same, we don't. I think that's great. Um, I don't know if uh the virtual audience heard that. Um, but we might need to repeat that in the mic. But, um, well, we got a lot of comments here that we'll hopefully be able to get to. Um, but, uh, and, and, uh, And Adrian's talking about that's what you learned from Keith Jorgeson. I know Keith doesn't do that now. I, I know for sure he doesn't. I'll tell you what he does now, but um we'll get to that. There's a lot of things to discuss and, so I'll try to go a little faster so we have time. Uh, my case starts at Uh, I think I have time. But here's the rest. Oh, sorry, Mark, why don't you play that video. Uh, OK. Got it. Thanks. Interesting. While we're watching it. So then here's the needle. And at this point in time, Craig was skipping over the vagin vessels instead of Dissecting between. So he skips over the vagin vessels, comes out, skips over. That's why this is so easy, and then you just go up and out. Very easy. It literally takes 15 to 30 seconds to do this case. Oh You can hear him, OK, yeah, go ahead. Just one quick technical thing is I, I go medial to lateral with that, and I initially, I started when I was across the patient. I was going lateral to medial, but a lot of times I would end up, um, getting. A little too close to the epigastric, so I would have to really torque my needle to come up, uh, really far away from the ring to miss the epigastrics, and I wasn't nearly as happy with that. So interesting, uh, so I always go you go the lateral. That's interesting. Um, I asked Craig about that, and he said he always goes right to left. In other words, he always stands on the patient's left side, OK. And he goes right to left. So on the left hernia, that would be medial lateral. On the right hernia, that would be lateral. That's what he does. I wonder what he does with the. Um, I think that hitting the epigastrics happens. And I think it probably doesn't matter. In fact, it probably gives you a better repair. Does, does he have a scar? Does he have to ligate the epigastrics, because I, I've been tempted to do that with my torquing, and gosh, it's just so much easier. I, I don't know. And Matthias Bruzzoni, who works with them, who does a lot of these, either he's gonna, when I go to the OR or we're getting ready, he's gonna come on and show it and talk about it, so we can talk more about the CO when you want, OK, um. I am not an expert. Now, Really where I'm talking about technique I thought let's, I know I have a slide in here somewhere, but let's talk about it now. Uh, about, oh right, cause we're still in extra corporeal, and I think we're gonna get to incorporeal where we talk about our tourist technique. So this is, now this has audio mark. Is that OK? Want me to pause it? This is a video demonstrating the technique that I use for, let me, before we start this. Da Darius Patkowski described his technique, and uh I think it's. Um, it takes longer, and this is the, but I think that it's more precise, and I think that having less stuff bunching together, I think you might get a better repair. So what I've done and I'm explaining here is, is modify the technique based on the research that we did in the lab with the rabbits. So I'll, I'll show you this now. So hit play mark. Alright. Yeah This is a video demonstrating the technique that I use for my laparoscopic inguinal hernia repairs in both small children and adults. First we're going to start off with an animation that demonstrates the basic operation. We 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 Because the hydro I said Sean. Melinda. OK, now it's the other way. Uh, that I was doing in Corrientes, Argentina. That's Marcela Bales translating or moderating the case. Um. Uh, and so this is being recorded with an iPhone, uh, videotaping the L the, the projector screen in the OR. So it looks kind of funny, but I'll go ahead and continue to play it. Aura delorelado and don't say vamosausa our salsa la who has fine needle queviron como se preparo colasabujitas. OK. OK, back up, back the camera. So I take an 18 gauge spinal needle, I pass it through. So you are before the busy pueabuo mora era pueera time pujandolosilitos. OK, and actually we just developed this is probably better because people can do this without any then I come medial and um and push this through that loop because the media I pass up the loop and you'll see why I'm using because they their camera stop recording. So then I pushed the 1st loop, the 2nd loop through the 1st loop and pull it up. And we're gonna show this over and over again, so you'll get it. But basically, I, uh, I go back, I put in one loop going, then I put another loop through that loop. The first loop is only there to act as a snare. It's not there for any other purpose, and I move it through and pull it up. And then there's a reason that we'll show this uh. Never. Always 30 polling. Always 30 polling, and here's why, um. It fits through an 18 gauge needle and, and it is stiff enough that you can push it through. Now, We are working in the lab with uh this, using this concept in a much easier way than doing this. Uh, so we have, we're coming up with a way that will be, instead of sitting there bending the needles and, and doing all this, a much easier way of doing the same exact technique. We're just not quite there yet. I use an 18 gauge needle no matter what. Yeah. So how does it work? Does the repair rely on the stitch for life? Does the scar, so by the way, what I just showed you is not the total way I do it. And the reason is that I want to give you some research background and then I'll show you how I do it now, OK? Because I left out some key elements of how I do the repair. Because these questions came up. That's how I was doing it. Then these questions came up. Are we really relying on that stitch forever? So I put that stitch in, I tie it down and that patient going to have that forever. Or does a scar form? From doing the manipulation, or does it work like a C? Are we tying it down and then does it erode through and actually it does divide the sack over time because that's how Seton works. So I will tell you that I've had two preemies that spit the stitch out. And they had not had a recurrence. The stitch came out, so it must have. Eroded through the sack and just just did a sea time so I didn't go in still intact. And so, uh, it's only been the preemies that have done that, by the way, and I think it's because the suture is just below the skin. Um, they got like a stitch out, you know, stitch, but they've not recurred. So I think it probably, uh, just Setons through. Um, That's Sean. So then that was what was going in my head. How do these work? And then I took a trip to these great, great guys down in Santiago, Chile, and Jorge Godoy said, Come here, I wanna show you something. And he took me in the OR. He goes, This is maybe crazy, but I want you to see this. So we go in the OR and this is the video that they showed me. When we get homework, I'll get it. This is a girl. They see the hernia. They pull it, the the very end, like you're gonna do a little, they hold it. And they just burn it. They obliterate it. They obliterate. You're destroying the patent processes bad analysis. Basically, what you're doing, Arturo, basically, uh, you know. Destroying the sap, whether you excise it or destroy it. So, Is that you? So, uh, we have a very famous author here in, in our midst, uh, Arturo Aran Aranda. Aranda is here today with us actually. And as we were just talking over coffee, he told me that we were talking about this paper. He says, yeah, look, I'm the author on the paper. So, um, uh, we've been talking about it. So what blew my mind about this is that if any of you joined our very first webcast, which was about 5 years ago when Momer Haddad talked about the fact that in the UK, When they do an open hernia repair, they just divide the sac. They don't ligate it. And we all thought that was crazy until he said, Well, what do you do for an orthodopect? You know, you, you don't close anything there, and he, this is based upon the understanding that For an indirect inguinal hernia, there's no muscle problem. But the patent prosthesis vaginalis goes through the muscle. And if you could bring it back inside, the muscles would shut or close. And, uh, so what they think is that if you ligate it, it's gonna maintain that patent process is still between the muscles. So you have to cut it, let it retract back inside the abdomen. And then The muscles will shut or close. So their recurrence rates are absolutely equivalent to ours. So, um, now Marto Romeme and Arturo, um, who's the other Romeme? His son, OK, so published a paper on a laparoscopic excision of the sac, and that's it, um, just excising the sac, um, laparoscopically, and, um. Um, So, uh, this is really interesting. So, a laparoscopic excision of the sac without ligation, um, So That brought us to the question of What, why, why does this work? We wanted to compare putting a stitch or, or, because obviously you're saying the scar is enough to close everything because you're not putting a stitch, right? So, right, not anymore. You were originally. So, uh, we presented this data in 2011 and this is what we did. The aim was to determine if a hernia closure is reliant on the stitch or Is there, is there any advantage of causing injury and that's what causes it, a hernia there. So we took these New Zealand white rabbits that have a congenital hernia. And on one side, we, we just did a suture repair, but on the other side, we first did a sharp dissection. We cut the sac only anterior. Only interior from 5 to 7 o'clock. We just cut the sack. Not over the cord. We didn't mess with the cord. The cord was left alone. We just cut the interior sack, and then we did the repair. OK, so stitch alone versus cut the injure the sack and then stitch. At that time we were doing seal because that was the technique I was using and we used a pole and suture and then we survived the rabbits for two weeks and Um, did an autopsy and then just survived in the 4 weeks. Yeah. to 5 I don't like to. Well, no, cause it goes. So, so if you're, you know, looking at this is 6 o'clock, I cut from here. Yeah, I just, so sorry. I go only if I just, I avoid, I avoid the cord. I don't cut over the cord. Um, So In the suture repair alone. Let's see. So, at laparoscopic evaluation, 2 to 4 weeks, we view the defect. First, we put in 4 millimeters of mercury, OK? Then we remove the stitch, so we put a little lap scope in and we cut the stitch out on both sides. Want to see did they stay close or do you need the sketch. Then we increase to a really high pressure. Which caused the rabbits to dissect. But, um, at 2 weeks out, the suture was removed, 25% stayed closed. So once we took out the stitch, it opened up, um, 75% of the rabbits. On the side with the injury, 87% stayed closed even when they cut out the stitch. But here's where it gets really cool. At 4 weeks out, 17% they closed, so almost all of them open. 100% stayed closed even when you took the stitch out just by causing that anterior injury. 100% and that's what blowing 36 millimeters of nuclear pressure. We could not get them open. Yes, and that's the flaw of my study is that I don't, I use heat. People say you can you really say for sure that the two are. But I'm in my brain saying injury is what I did. I used scissors in the OR now. I use cautery, but there are people that have taken this study and now use scissors. OK. So you can use any way that I think the idea is causing an anterior injury. Um, And uh The question of what size prole, I use a 30 pole. There's a lot of questions in there, and we'll stop in a, in a moment and go through as many of these as we can. And if you wanna call in for a question, just tell us and we'll open up the mic. So, and the conclusion is that you need to cause, I think you have to have trauma. The, the analogis is if you take your cheek and you hold it like this for 5 years and you let go, it's not gonna stay shut. So you're relying on that forever. Then we looked at the suture matter. So we did the same repair, but we tried silk, vicro, and pole. And at 6 weeks, the suture was removed. And this is without causing any um injury to the uh peritoneum. So without causing injury to the perineum, the vicro, almost all failed. Prole, almost all failed when you cut it out without causing injury. But silk, um, most did not fail. So the question is, is a, is a braided suture work better than a monofilament? And does it have to be a permanent st without injury, without injury. You got it. Is it a braided suture causing the injury itself? So, um, because of that, we now use a graded suture, but the problem is I told you I use a 3 year old colon. So. Um, we now do the Keith Jorgeson modification. So what we do is, after I get my loop of pulling all the way around, I exchange it. So then I have my loop rolling, then I put a 2-0 at the bond or whatever you want, any kind of braided suture. I use a 20 at the bond. I'm putting that through my loop. And then I pull my loop back retrograde, and it exchanges the free ends of the prolene with an etha bond which exchanges the prolene suture for the bond. Don't know. Just because, yeah, I have no reason. Yeah, no, no reason to leaving two independent sutures which are then tied down. And silk Yeah. Yeah, no, that's a good point. Um, so a lot of people have asked me that, and I have no, I don't know why I. You know why I use ehebo because that's what Albanese used when I learned SEALs, so I just learned using an e. This. So I've had two stitch abscesses, both in preemies. They spit out the stitch and the hernia stayed closed. But, uh, you know, that's a problem with a braided suture, no. But based on this, my partner, uh, Oliver Soldis said, wait a second. So you just showed that after 4 weeks, injury alone is enough. You can cut out the stitch. Why not use that? So, because I'm a wimp. I want to study it in rabbits first. So we are gonna do a rabbit study one more time using just injury and vial. If you saw the vico failure rate was 90%. Now I want to go and see the vico failure rate with. I just wanna see it. So, absolutely, yeah, I will. Yeah, that would make the operation much better. A stitch forever. Yeah, I hear you. Which abscesses, yeah. It's a great point, yeah. You know, I, I don't know why I use the pottery. Um, it seems easier just to, it just takes 2 seconds plus, um. You know, not gonna be any bleeding, not that the bleeding should be that much when you're just cutting peritoneum, but. That's true. Reading probably helps, but then I can't see when I'm passing. More regular. Put the electricity on it. It Right, right. Right. See, that's why this is good. I'll probably change my technique. So I, I do change. I, I always, if someone tells me a technique, I always try it. Always. I will never, I never not, I think the only one I haven't done is yours. I haven't done a complete excision, um. Yeah, yeah. Which part For sure. So um when this first started, I first started doing this. The question was, do I tell the family when I'm doing a new technique? Now, as Aaron can tell you, I'm always doing new techniques. OK? That's, I, I love trying new techniques. And so I'm frequently faced with that question. I, I, I assess the risk tolerance of the family. If there's any hesitation, I don't even offer it to them. Or if I offer it to them and they're hesitating, I say, never mind, let's just do it whatever. So that first conversation is always open versus loud. I tell them this is what I do, but I'm willing to do the other way they want. And then the question is, if I'm using a new technique, I'll tell them. I'll say we've been using this new, this technique traditionally. I think this other technique may have different advantages, and I think it's worth trying, OK. I, I don't think I've ever had a patient tell me, I've had patients say didn't want to open. And I, I And I don't think that that's wrong for them to ask. Um Anyways, this is a briefcase I want to show you that uh Garrison and I are presenting or or not presenting, submitted to the American College of Surgeons. There's a case I did last week or two weeks ago. There's a kid in the NICU, little tiny, tiny little preemie, 1 kg kid when we first got called with an incarcerated involvement. Couldn't reduce it, pushing, reduce, finally got the thing reduced and pops right back in. Pushing and pushing the pot right back in, but In the NICU, in the NICU, right. So then I got an ultrasound because I was like, I want, well I, I so I reduced it, then I got the ultrasound to see, is this really like back in? Is it just swelling? What's going on here? And they said, it's almost all reduced, but there's a little bit of appendix still in there. And this kept happening. I would reduce it. And so the kid was not incarcerated anymore. There was a little bit of, it was like you could push it back in every time, but whenever you push it, it would pop right back out, but it was soft and red. So we waited till the kid got 1.5 or Little older a couple of weeks. Tons of erythema. Pushing on it Right. So we decided, so I took him to the OR and this is what we found. So, His appendix was stuck into his gubernaculum, so this is a true amnion hernia. The appendix was absolutely stuck inside there. So, I did end up putting in 2 more instruments. And you could see the chord structures separate away, and I, and in the, you see the cord uh structures. Can I put like an Air wallet video. Let's see what happens. Yeah, I'll show you the code structure is gonna happen. So now I'm just dividing the attachments, but I was worried because I was like, I. You know, I want to make sure those cord structures are definitely away from me, so I kept checking like every. Yeah 2 seconds. And this is actually I just realized this is not my final edited video so it's probably the one that needs to, but the chord structures are down here you can see it. It's still just dividing the attachments to the gubernaculum. This, I don't know, Aaron and I were discussing, would this have been more challenging open? I don't know. It would have been interesting because when you go into the groin, your appendix is right there. Uh, you can't reduce it back in. You have to do your hernia repair with an appendix right there. I had this case as a as a fellow through the groin and it was really, really, really hard. Yes, validated everything. OK like what we would like good. All right, validated mid-level attending an appendix. It's, it can suck. It could be really scary when you're Right, the slider. No, but you can't tell because it's in the sack. Right, so you'd have to see what it is, which is what you'd have to do, yeah, I'm glad to hear that. So, and then this part I was like, wait a second, this is like some hard structure. Is that vase? And then I kept looking, OK, no, no, here is the vase. He is the vase over here. I'm not. I kept looking, I, I kept looking over and over. This is the tip of the appendix right here. Tip of the appendix, and it's got this attached. I kept checking. OK, there's vase, there's vessels. Definitely not dividing anything, so. Something, right? Yeah, more structure, but I can't look, look, look, that vessel. It is essentially, yeah. So then I reduced the appendix then, um, so the, the, the title of this thing I submitted is 4 reasons to do a lap hernia in a single patient. One is the AI on hernia. 2, is it's a preemie and it's easy to do it in a preemie. Three, as you'll see in a second after I do the repair, is that I went ahead and did the other. She had a bilateral hernia. So I did the other side. Um, but here's my injury. Chat questions? What do you do with hydroseals? Tom asked that question. Um, Tom, I've done one hydroseal repair laparoscopically and it worked great, but I don't routinely do that. I usually do them open. What I did is I pushed the hydrocele into where I could just see a bulging into the peritoneum, and then I just popped it. And that made me less excited because I think when you just pop a hydrocele, it's gonna recur. So I did it once and it worked, but I Now I do them. My hydrocele is open, and I'm curious if anyone does those laparoscopically. Right. So I, the question is, what's the difference in just aspirating a hydrocele versus popping it? I did more than just a pop. I like made maybe a, yeah, stretch, and I stretched it open and pulled the hole. So, but it's still just opening the hole. I don't, I didn't resect anything. I just sort of stretched it and opened the hole. So maybe no different. But does that give you an idea of my 5 to 7, what I mean? It's like just the interior stuff, but I don't, and I don't know if that's as good as cutting. I may need to cut. I don't. So anyways, and then here I'm, I'm hydro dissecting. 25 gauge And then I passed the I use marking Vivocaine, so it numbs up the groin. Now if they do a block, a quadd then I'll use saline. But also No, from exactly. So that's a great question. Is that when you hydro dissect, do I, do I do it from the Do I do it from the um Do I do it from the the 12 o'clock position or from the side, and I go really out lateral from the side because you want to just come straight in and lift that peritoneum off. The perineum always lifts so easily off the court, off the vessels, but not that easily off the. My, my concern is I, I think the hydro. the I think even a scrotal hernia with this approach. I'm worried about post-op. I've never had 10 damn, I have to say I do now. So I just had one. I've actually had two. I had one when I first started with this. Oh, with the seal technique when I first did it, I got, I had a girl. Both these cases are very similar. Did a girl, and I saw she had another hernia on the other side. So I like it. She got a canal of this year, OK. It went away after like a month. Just went away. I just did 10, this kid, this kid, I did, I did the my technique on the one side and then I was showing the seal technique on the other side because I think they're both OK. I just wanted to showing and they got a hydroseal on the asymptomatic side on the left side. So both times were on the left side that were asymptomatic that I fixed with the. I've never had a hydrocele foam. This technique, and I don't know if it's because I'm, we all learn how to do hernias by, you know, putting the two clamps on both sides of the sack, your high ligation and deal with the business sac, right? So how do you explain never having like it was, was that just another surgical myth you want. You know, just that you have to deal with the distal sac. I don't think you need to deal with the distal sac. I don't usually resect my hernia. Yeah, I don't resect my distal sac. And so I do you guys resect your distal sacs? I do make sure I like it and I don't resect it, but I penetrate it, yeah. So, um, the There's a theory, the question is why would you get a hydrocele? Cause you've ligated it, where would the fluid come from unless it's a secretory lining of the sac. Where would the fluid come from? You close the hole. So if it's a secretory lining in the sac, maybe the reason that my usual repairs don't get hydroseals. is that I'm causing injury. Maybe I'm destroying the blood supply to the peritoneum. I'm making stuff up right now. I have no idea. I don't know. Um, all right. So David Mer Meager says that the fluid does come from the lining of the sac. So, you know, I don't know. I think I'm destroying the, I think I am killing the sac by ligating it. I think by ligating it tight, I'm I'm killing the sac. I don't know where the blood supply comes from, from the sac, the knee. Not a problem. No, I've had 2. I would've, it would've been 1 that I would've said until yesterday where I had my second one. and, uh, So You know. What what we do what I do, which is based on the government's observation that I were talking at the beginning. Uh, that you know, I shouldn't really come in when I was, when I was staying with him, he was, he was doing laparoscopic orthodops, and when it was bilateral, we would do one side, there the bilateral and we find out we, we, we saw that the side that was that we didn't have a hernia when we came back three months later it's completely. So based on that observation, that's why that week and So it sounds like we're doing a lot during the operation, but Actually, yeah. What we do is basically you, you're using the needle close to the vas and the vessel, and you know you cut and then you basically do the same, you do the cut around it and then instead instead of getting a needle close to the vast and the vessel, actually just use a blunt blunt Maryland and it's, if you, you know, you, you say that it's easy to pass the needle away from the vass and, you know, between the plutonium and the and the bass and the vessels. Doing a blunt dissection, it's even easier once you just do that and push it down very safely, if you're just pushing it down gently, then you have a circle of that. It's just full and complete. It just, I wanna ask a favor. I if you have a video of your technique. OK, maybe I've been trying to, I've been, I've been texting to him and see if he's available to call and send. I know he has videos, yeah, and yeah, and I do have videos, but I, I didn't come there. If you could maybe even after this event if you're willing to share it or even just so we can. People to download it to watch. I think that, I think that, um, I'm, I'm interested in, in interested in understanding the technique. I again, you have to understand when I'm looking at the technique I'm looking at. One is I find A hernia repair that would have the masses that would have the lowest, it's almost like a Nissan. You know, um, Ashcraft had great results with the foul repair, but for the masses, the results were not that good. I think if you're going to come up with a technique like this works seemed to work well for him, I am wondering. And I'd be curious to hear if you guys do courses with the, what you hear from people that learn the technique, what is your complication rate, not from you guys, but from the masses. But I will tell you that if there shows to be a significant difference in my results versus yours, I would switch tomorrow. Not today, tomorrow, yeah. to that because need to Because you've opened it up so you can get a Maryland in there, OK. What in case everyone doesn't understand, uh, Arturo, uh, does a complete excision of the sack, and then he, but you don't put stitches now, so you don't have to do that. Oh, you're doing that dissection in order to do this section of the sack. I got it, yeah. G I love it. OK. Let me ask you. I wanna, I wanna challenge you now. If I show the same occurrence rate as you. With anterior injury alone. And you can do this with a white girl. Why would you still do your technique? The we the things. The The big ring there was nothing we could have. You're not even. Stops. Recovery room. So what about your organ apexes though? I think they, I think when you stop insufflating, when you stop, I think we're being confused because when we go in. We are insufflating. We're blowing up. It's like you're, you're putting a retractor in and you're lifting up the muscles. When you take out your insufflation, the muscle should shudder and there's just this closed peritoneum that's running through it. I think. There's no way to know. I agree, I agree, and that's my problem with it too, but now I'm trying to make their argument. OK. They're wanting to hear our. No, I There are people are wanting to do the next time I'll pass you the money. Um, but let me, let me try to just say what, let me try to repeat what Arturo was saying, and I apologize that people couldn't hear. Um, let me, let me repeat what's been said. A lot of discussion across the world is being talked about doing a complete laparoscopic intracorporeal excision of the sac. And my concern with that is that it's a pretty, uh, it's a little more invasive. It's a little more risky, I think, to try to get the sac off the cord structures. Arturo is explaining technically it's really nice because when they make the score, then they can actually get their Maryland in the in the score of the perineum and actually dissect with the Maryland that off us off perineum, making it easy to excise it. Is that, is that, am I paraphrasing well there? OK. And so our question to each other back and forth is if I can show that only anterior injury causes the same recurrence rate. As complete excision, would he switch or would he still stay with it? And I also would say that if he shows a lower recurrence rate, I would probably switch to his technique. I don't know if you need to get the entire sack or just make an injury. I don't know. That's what we're debating here. Question, the question was, do you use uh cautery or scissors. Uh, the ring around the fishing around it. The thing er that he goes away from the bathroom the vessel just, just scissors, just scissors, not even, not even, we don't even use part of it and, uh, and, and he said Marinon, but it could be any blunt once, once you do the incision around the 5 to 7, it's just any blunt. Uh, grasper or whatever because you don't even have to spread. Once you have that, you just gently lift the sack and, and it gets separated from the vas and the vessels. There's a question for you, uh, from David. Can we put our two on camera too. Yeah, OK, um, there's a question from David Meager. Do you just divide around? Did you know you were going to become the center of the show today? No, David Meager wants to know, do you just divide the entire neck or do you excise the whole sack? No, we. So, so then, so it's 5 to 7, bring incision, and then gently separate the, the, the red, the, the below portion of the gently lift it and you get separated from the the vessels and then cut. That the face on. It's it's already separated, grab the whole ring of the attack. Pull. Then if it's a big tap, you can separate also the cut. You don't go crazy if it's a big down tap, you don't go crazy. You take as much as you do. And once you're done, it's a, it's an area that deeperation around the ring inside so. That the, the, the idea is that we get rid of the processors, get rid of the memory, and, and we, OK, so I do remove the fact as much as, as much as I can without going crazy, without risking it. So, um, that, that's, these are all the questions that are brought up, um. The uh whether or not you have to divide the sac, remove the sack, cause injury, because in theory we're doing almost the same as we're we're removing the. I Sounds good. OK, good. So here we're doing this. What are we doing open? We're removing the professor, and the only thing that I have to argue about the needle is that we move the professor, and I, and, and I'm happy, we should, we should be, you know, um, we should do the data, and, uh, I'll be happy. I've been trying to get a hold of the government because he's the one that's been doing this. More, it has more gigs will be interesting for me. I need to see a substantial difference in the contract, which can't be really because ours is pretty low. I mean, I think I've, so I've, with the new technique I've done, I've not had a I've not operated yet on a recurrence. I'm sure I have them that I don't know, but it's got to be pretty low, OK, um, and I'm always, always open to change because we, and as I said, this, we've changed what we've been doing, right, try to optimize it and make it safer and faster. So let me tell you my concern with the lap hernia repair. There's so many techniques out there, and so when people report the recurrence rates or the, the lap hernia repair, you can't compare apples to oranges here because. We have to really refine and figure out what is going to be the technique that everyone's gonna be using, and I think it's gonna evolve over the next several years, and we can't look at your data either. Absolutely. That's the reason I can't publish. I can't publish my data because I keep switching. So I, I like if I publish my data, I can publish my last. 2, no, 2 years I've been, you know, because I've been doing this for 2 years now, and what's that gonna be? Not, not enough to get the data. That's why I'll never be able to publish because I keep searching. I have to stay with what I'm doing, but I know. All right, um, I love how it's sitting down with that circle behind my head. It looks like I have a halo like. OK, um, let's, before we go to, and Mark, I'm wondering if I can, I wanna show a video. That's not in here. Can I share my screen? I have, OK, um, will it have, will it have the audio, or no, I'll just pop over. OK. So, um, Things that, but, um, let's go through some questions. Then we're gonna talk about adolescence and then we're gonna finish up with the last few sides and then we're just opening up the discussion. So, um. First of all, Adrian, can you hear, um, were you able to hear Arturo better after we moved the microphone? Let me know if the mic is in good position. Let me go to Tom Curran's question. Tom says, does anyone use the Endolo device? Uh, Adrian says he can hear. Good. So, uh, Tom, uh, I have not, but, uh, the guys in Kansas City tried it and they told me they tried it. The EndoClose, for those who don't know, uh, is a device that basically you push a button. It's The needle that you push a button and the little hook comes out of the end of it so you can drag the suture through. I do think that's a great way of doing it. Currently, the endocorse is not designed well. They stopped doing it because it's a rigid straight thing and it's kind of too big and clumsy, so. No. I don't mean endo quote. It's not the endo quote, Tom. It's the uh Uh, it is the endo clothes. Endo clothes. You're thinking of endo stitch. Endo clothes is just a, it's meant for closing laparoscopic holes. It's like a little needle. It's like a carter. It's like a disposable. Disposable suture passer and a lot, and I do think that is a fantastic way. But right now, the, the big old things are not, they, they switched. They said don't use it, it's too clumsy cause I was gonna try it too. So, uh, yeah, Christine White says the, the, it's too, uh, too big. Yes, the Carter-Thompson is another way, and I can tell you that there are other options, um, that are, that are gonna be coming that will, will be much, uh, better. Um. There's a lot of questions. Let me try to go back and see some of these before we go and then I wanna open up here. Um, interesting. Christine White says cautery from 3 to 5 o'clock may get the nerves on the right and opposite on the left. I hear what you're saying. And then that's why I, I don't know what you think, Christine. I'm only cauterizing the peritoneum. Um, I'm, so I don't think it should cause any nerve problem. And I will tell you, and everyone talks about anecdotes, that's all I have, unfortunately, that, um, My, our pain control from the nurses in the PACU telling us that they don't even need to give them anything and that was surprising to me because I didn't think it would really be that much of a plus, especially since I'm causing cautery, um, but they don't seem to be having a significant amount of pain and I have never had any chronic pain, um, with any of these, but I think probably no one has had patients with chronic patients. Um, we talked about the hydroseals, um, Would you get better inflammatory responses changing the bone of the silk? That was a question that was asked, and, and that's something that I would consider. But we do think that you get better inflammatory changes by using an Ahabo or at least a braided. I don't know if it really matters, but it might. A braided suture seems to be a braided, non-absorbable suture it for now, but we might try a braided. In Chile, do they cauterize the sack to obliteration for the boys too? No, definitely not. This is only for the girls, Adrian. Sorry, I didn't clarify that. Um. Uh, let's see. Yes, um, do you have any age cutoffs at all? I mean, it sounds like you're doing things. Like, is there weight or age and a 35 year old wait and see. We're getting to the end of the talk. This is the last part of the talk. We're going to get to that. Yes, that is, that's my, that's my most exciting. OK. And then along with that, maybe that is like, are there certain, we talked about hydrocele. Are there other certain scenarios where you, so, uh, a direct hernia, a hydrocele. Or the one time I've had to convert, but when the kid's colon was all stuck to The, the, the signal was somehow stuck off to the ring and I just couldn't see in one of the cases today I may convert. What's that. I don't know. It was a weird thing. It was the way it was, he didn't have adhesions. It was just stuck for some reason. I just couldn't see well. And, uh, but the kit I'm doing today is a post-op Ay. You had a hernia and I don't want to fix a hernia in the face of an infective operation, because, first of all it was asymptomatic. That's a whole another debate. If you're doing a pyloric and you see a patent processes to fix it. That was another one of those, uh, all of those courses where I raised my hand and say, oh yeah, and no one else did. So I quickly dropped my hand. So, so now I, I don't, but, um, but especially in an infected case. So this is a kid that's coming back now with a symptomatic inguinal hernia that I'm gonna do today, and it might be, uh, at, at ease down there. Um, What about um for the bladder? Yes, I, I create the bladder, um, before these cases. First of all, I never put holes in any of my patients. And no matter what the case is, I don't put holes. I just, or I have them pee in pre-op. I have them pee in pre-op and then I, uh, and then I do the case unless I think it's going to be a big, huge operation that I'll. Uh Yeah, right, yeah. Um, Tom says, I recently had a preemie twin boys with indirect left inguinal hernia and a direct right inguinal hernia. Oh, interesting. So both preemies have the same thing. It sounds like. The first I did open and missed the right inguinal hernia. And then I found I missed it a few days later. The second, I did laparoscopic because of the experience of the first, um, lap left and opened to see me right. So, so these are congenital acquired and not due to damage to the floor. So a lot of people have been saying this. I've been getting emails that people think these are congenital direct hernias that we're missing. Which is a great reason to do laparoscopy. Or like, uh, that's Adrian that always put in the same stitch, so yes, you know, not really care about your high if you think that's enough, yeah, one stitch, yeah, I mean, it's a great question, but then Yeah, um So we talked about published risk of recurrence and um we talked about the round ligament, um. Mark, can you put up a poll? Um, first poll is, do you divide the round ligament you do open? And the second one is, do you do laparoscopic or? Um, What do you do with the small asymptomatic hernia seen at the other labs at other, we just talked about that. So it's funny Adrian put that up there. So it looks like, uh, and we can ask that here. I mean, does anyone, would anyone fix uh an incidentally identified patent processes? You would with the girls that I've done, I, I put an instrument. I can put an instrument through there and it goes down, then I fix it. If it's just a chicken hole that I can't in a girl. Do you go out and talk to the family? Yeah, OK, so you leave the OR, go talk to the family. I, I book every left hernia as possible. I will talk to, yeah, if I didn't include it as possible or something like that, but usually I agree. Sometimes it's that little winding thing and it's like a centimeter.5 long. I, I, I, I don't know. Yeah, I, I do with you. I put my, my instrument in if it's enough that it goes in a little bit or you know put it up. It goes in a little bit. That's, you know, you do it, yeah, I would just go it, it might go in and I do the same thing except this guy just put the end of it. Yeah, what I do. Let's choose the other option. Yeah I mean with the endo loop, it's like an easy case. It's like when you do 3 girls in a row, the residents like look at it they're like you're cheating. He's like it's a non-operation. Um, I, I, Whitt Holcomb had, had, uh With Holcomb had an issue with doing the operation at that time without having a good, uh, explanation to the parents ahead of time about hernia repairs and why you're doing them and doing that. So that's why he said you shouldn't. That was his point on why he doesn't do that. Um, it's value. So, um All right, let me try to find Mark. I'm gonna try to find my um Uh Yeah This is, this, you don't want to see this. This is um So, So I'll just to share my screen. So this is because I, I didn't have this in my talk, and I think you guys might want to see this is the setup. Um, Oh yes. When I'm ready. Any questions before we show this video we're waiting here. This is gonna show how I prepare my needles now. I just told you that we 3D printed these little things that I'll, I'll use today for the first time, but they just, it bends the needle instead of using needle drivers cause it makes a kink sometimes in the needle. This is, yeah, smooth bend. You're good. Mark, I have this thing here. I don't know what that is. Just click on the menu bar. This 3D vendors. So you make one every day. This is a video demonstrating it's a it's a sterilizable hernia repairs and you guys want to know and adults. First we're going to start off with animation. This is what I showed you before. We'll show this again. You start off with an 18 gauge spinal needle through a tiny 1 millimeter incision because I can't animate this needle is actually going through that skin incision. I just don't know how to do that with PowerPoint and pull the needle out. That's a through the exact same incision. We comely and, and slide another looping through the first loop. Then when we pull the first loop up, it acts like a snare pulling the second loop. Around the hernia. And because we prefer to use an Ehabo suture at the end because it's a softer knot and it works better, we then exchange this for an Eha bond, cut the ends off, and we do the ligate. Here we're gonna show it in a couple of what? Oh, OK. This is the first case. Again, we start with an 18 gauge spinal needle. Some people use a 2 needle which has a one to curve tip. I then curve the tip. It's a gentle curve because if you make it too sharp of a curve, the prole won't slide through. I like to use a prolian suture initially because it's firm and it slides easily down the. Needle. I cut the, 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. In. 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 of 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. So that was the part that was all I really wanted to show was the preparation. So bend the needle and you pass the ends to cut the loop, the little curvy parts off and send it retrograde to the tip of the needle. You can also crimp the loop and push that through the back of the needle, but one time I've had that when I was pulling it through a grip because I had crimped it and destroyed the integrity of the suture. So now I always put the tails through. Yeah. But the, uh, the, the important thing is that, and I actually have my nurses have two spinal needles on the table. That's a little bit of a waste of money, but I have them all pre-threaded, so I never am waiting to do this. They come to start the case. I do one and the other. It's all set to go. Um, if error on the side of less curve, what, what the hard part is when you pass the, the suture through, it gets stuck in the needle. It's too sharp of a curve, and then you're in there and you're going like this, and it won't pass through the needle. Yeah, right. That's why, that's why just to let you know, we're gonna be, we want to make pre-bent needles because that's, that's why I bender. Yeah, well. The vendor or even just prevent needles, one or the other. I mean, it's just crazy to, to be doing this. But um we, we're gonna be, we just bend it slightly. And, and then pass the suture, otherwise it'll get stuck. Does that, does that make sense? Any questions about the preparation? Did I make that clear? OK. Last part of the, we're going to finalize here in the last 10 minutes is about the adolescent. So what about the ones in the middle? So, When, when would you just highlight it, forgetting laparoscopic, when would you just highlight it? Would you highligate this child? Would you highligate this kid, this kid, this kid, this kid, these kids? When, when do you decide it's time to do an adult repair measurably there's that, uh. With the data that Last time I heard Jorgerson talk about it is the higher recurrence rate in teenagers. So I think he was in one of the fellows courses he went to, he was advocating mesh adolescence. So the only, I don't know of any studies that's shown except ours. I don't know if there's another one that I didn't do a good literature. There might be. You're smarter than me. So if it's out there, then you're probably right. But we, we published our series two two-center institution with um Kansas City and when I was at Rainbow and the recurrence rate was 3%. That was for both institutions. So can you define what adolescent 13, we did 13 and higher. 5-year review of 13, I mean 13 to 1813 and above. I think it was 13 actually it was, no, this for this study, it was 13 to 18 for this study, um, but it was 3%. And then what was interesting is not only was our mean 3% individually was 3%, ours was 3%, theirs was 3%, and that was uh, we waited, it was a 5-year follow-up called in with a survey study. Did you have surgery? Did you Uh, have any symptoms in your groin, you know, blah, blah, blah. Open. That's open. So I mean I've had a low threshold since I've been independent for 8 months. 3 or 4 adolescents I've taken care of. You have mesh. And so it's funny because the adult hernia surgeons. Freak out. They're like They send it to me. They're like, you know, we don't want to be putting mesh in, in a, in a, in a young patient who wants to have kids because we know it causes infertility, it causes chronic pain. You know what the incidence of chronic pain is? So the huge, the, the biggest study, that's about what people are quoting now, 10 to 15%. There was one study that showed 30% incidence of chronic pain, which is what Mike Rosen's What I tell the balance is, um, you may have a higher recurrence rate with just high ligation, but I'll take the higher recurrence rate to avoid the 15% product exactly what I tell them and I mean in case everyone didn't hear that, um, uh. Uh, I have a 0. Uh, Nathan, Nathan says that he does, um, uh, he tells the family exactly what I tell them is that you may, we don't know, you may have a higher recurrence, but that's better than a chronic pain. And so. So, but guess what? Our even 3% is very low compared to what the adult. But here's the, here's the question. So then you get the adolescent that you've had this conversation pre-op, but it's a giant big hernia, and like it just, it's just you, the high ligation just doesn't see the direct component so, growing the rectum. Right, right, well, so, um, So just some a couple of things, well, I'll go to these questions later, but let me, let me continue on here. So, um, I think it's a big ad opener. Aaron said to me the other day, do you do these in adolescence? I said, yes, I think it's great for adolescents because it's a big, big repair in a big adolescent. And you're doing like a bigger bigger incision. You're really grabbing stuff. I mean, it's just a big repair. So is this a video I have? Yeah. This is my last video. So this is my laparoscopic technique, OK? Now, uh this is not me doing it, to another surgeon. Um, And I want you, you've seen how I do it. I want you to tell me if you notice anything different about this operation. So here he's passing the passing the needle. Now, he had trouble passing it from his kink, so he had to use a Maryland to pull it out. Now it's coming medial. He puts it through the loop. You. So the first one. Yes. OK. Did you see anything different? Yeah OK. This patient is 80 years old. Guess what? I think this works in any patient that has a small indirect inguinal hernia. I don't care if they're, they're 8 or 80. A small indirect inguinal hernia is a small indirect inguinal hernia, unless we are thinking that somehow things change. Now, can an indirect hernia, indirect inguinal hernia become a muscle problem? Can it start off that it's truly not, like we say, if you desufflate and everything collapses, it's really the muscle there with some stuff in between. If you pull that back, it should be shuttered closed. Or over time, does that indirect inguinal hernia stretch and become a muscle problem? And does it need mesh? Mesh was designed for direct inguinal hernias. Mesh was designed for a muscle problem, not for an indirect inguinal hernia that is not a muscle problem. So what is it? 17 years and 360 days? That's when we decide they need a high ligation, but once you get to 18, they need mesh. It's crazy. It's got to be the same. So we are doing an IRB approved prospective trial in adults of any age, of any size. There's no limitation. The only limitation is how big the defect is when you go in. If you go in and the defect is bigger than the Maryland's spread or 2 centimeters. We're converted to a tap. OK, they're attacked, even if it's just indirect, even if it's just indirect, the concern initially, maybe the second studies is we can try even the bigger ones. But I think for a small indirect inguinal hernia, and especially, I think that you're gonna find these in young patients in their 20s or 30s that still want to have kids and have bilateral small indirect inguinal hernia, they do not need bilateral mesh. And so again, we tell them. There may be a recurrence, but it's certainly better than having, uh, you know, chronic pain and issues of mesh in your study they switch to a tap or do they do, they do a tap. So the only surgeon. Correct, so the only surgeon that can participate are tap surgeons. Tap surgeons can't participate. Yeah. Does that make sense to everyone? If you're intraperineal, you can't, you're dying. So, um, that's a limitation of this. You're committing yourself to now all you have to do is put, even if you put a little cam, I wonder if it would ruin it, you put just a little camera into the umbilicus and look and see, and you see that, can't you still do a tap? I don't know. The adult surgeons in my, yeah, so, and, and I hated that operation when I trained in general surgery, but I've seen some, some of them do it now, and it's. Quick, easy, and they're very happy. Well, I think, I, I, I, I don't even know what I would do, um, temper tap, I think, but the, I think guys, we're gonna see that, that, that I'll, I'm gonna be shot and killed by the mesh companies. But I don't, I don't think, well, I'm not saying we don't need mesh. I'm saying that we might be using it a little too much. And I think, you know, when you talk to the adult general surgeons, they rarely differentiate between direct and indirect. When you talk to them, they're like they had, they had a hernia. The reason they don't because it's the same operation now. They just, it's a hole and they patch it. There's no, but now they need to go back to the beginning and say, guys, if it's indirect, it's a patent process. It's vagin analysis. It's still the same. What they know the technique or they call you in. So the IRB approval is that I have to be there for 4 cases. Oh, Mark, can you have my, my telementoring montage? I do. Can you load the telementoring montage and then this, this, uh, if you look up non-mesh in Dropbox, it might be there. Um. Then you can upload both of those uh. Both of those videos and you can show them. So one's called non-mesh and one is called Elementary montage. Um, I have to be there for the 1st 4 cases. The last case, I was in jail. And so I telementored the surgeon using telestration and, and drawing and everything with laser and everything showing how to do it. So, That's the RB for this pilot study. Then we're opening up to 5 institutions after this. Right now we're doing a single institution, 25 patients, mostly adult surgeons, only adult surgeons. I'm not. No, I'm done. Well, I'm gonna go back and do a retrospective of my adolescent population, but again, my data sucks because I keep changing my technique. So, um, let's see what some of these questions that we have. And then if you guys have questions, and then what I'm gonna do is, I don't know if Matthias Bruzzoni is in. When I go to the OR he'll, he'll come in and, and, and, uh, and talk and show his technique. Um, Yeah, Doctor Mager says mesh has far too many complications that are very serious, and I agree. Um, What you do with the small asymptomatic hernia seen in other lab, we already talked about that. So, um, Right. By the way, here's how I always book my lap hernias. I, I have not here yet, but when I was in Cleveland, I had a standard consent that said, Laparoscopic, possible open left possible right. Or possible left, possible right. And it's the same for every single patient because if you have your resident's consent for you, it's always gonna be wrong. So just have a, uh, one standard consent that says that it covers every possible thing you start doing it, everyone goes crazy roscopic they get so confused. It's gonna confuse. They go lap, it's not lap look. So, um. Um, we're going to talk about when I do my first case, I will really show you the full setup of the OR. We'll zoom in on my tray and show you what I, what I open, what I don't open. I use a 3 millimeter scope. So I put in a Veriss needle, I put a 3 millimeter trocar in, and I put a 3 millimeter 70-degree scope. The big patient 70 degree and you'll see why today. I wonder if maybe I'll try a 30 to show you. It's, when you're doing it, it's not, you really want to look around the ring like this. It's a little harder with a 30 coming from the middle, trying to see off to the side. Um, so a 70 degrees better. I saw in your setup video that you cut off. make an incision or I do an intern buildable incision, and that is just, just how I do it and I have done through the umbilicus. The only through the umbilicus is fantastic for a couple of reasons. One is really a hole there. It just pop right through. To, um, in certain patients, it may be scars. I actually believe, and I would love to do this study, that an infradocal is better cosmetically than a trans. And the reason cause everyone talks about trans, but I think you, even though we think it's like all wrinkled and stuff inside the umbilicus, you can see a scar and it's right in your face. It's right in the middle whereas infradocal is hidden on the inside. So what I do, and I'm not preaching this because I will tell you that there are people. And I do both. But, and this is not my idea. I learned this from Rothenberg, but I inject the inferior portion of the umbilicus with a ton of marking, and so it lifts it up. Then I cut. So when the marchan's gone, that incision's actually not in for umbilical. It's actually in the umbilicus, but on the underside. So because there's usually a lip on the inferior portion of the umbilicus, that's actually really hidden, better than going right through the middle. That's why I do it. Does that make sense? It's in the lip. But I have patients that I absolutely do. I mean, my pylorris, I don't make any incision. I just pop in. So, um, what other, uh, questions? Um, here's a comment. It seems that, uh, most of my adolescents have large hernias. The rings are stretched and it would seem to me that the floor of the anal canal is stretched and compromised. Adrian, that is the big question. That, that we're wondering. And that is why the study for now is limited to only small indirect inguinal hernias. If we see a huge monstrosity of a defect, I don't feel comfortable yet saying that that's truly just a patent process. I think over the years that probably has stretched out to become a big direct. However, you may find that even those can be fixed by just bringing the sack inside and, and things will go back down to normal. A stretch may go down. A direct hernia is a defect as a whole. A stretched ring may may go back down if you take away the, the insole. Any other comments or questions? I Which one do you got? So, totally unrelated. This is, uh, I just, we submitted this to IPEG, but um I wanna show you, um, this is how we think we'll be able to, to get for something like this so that people don't have to go and spend time. We can do telementoring. I mean this is a brief montage showing that. And you'll see the hernia at the end, right did from Vail. Is there audio? Not a. They're on here or no? Yeah, all that stuff there is probably should be mentoring me through you would divide up the lower lobe and it'll help pull it away so you can get as much length as you can like. That little red line going down there seal don't seal there. Just get the vessel, the vessel itself, and use just more of the tip of the instrument so you can see it. Well, you know, see, see the little red. About, about 4 millimeters to your left, there's an edge right where that little red thing is. Yeah, you can get in there and open that up, but you want your clips as close to the diaphragm, but you want as much length on that vessel as you can get. So Steve, you're going to want to put the simulator right there. And you're going to want to put a 5 millimeter port right there. And a 5 millimeter port right there. So what I was saying, Steve, is that normally you're supposed to take a 10 centimeter silk and measure 10 centimeters up from the pylorus, but my guess is That G tube is going to be right about where 10 centimeters is, so I usually just go, nice job. Thanks, doc, I really appreciate it. That was, that was very helpful. Thank you. That was fun. This works really well. Yeah, I did. And then there's a direct defect, and there's a medial umbilical foam. That's nice. That's great. Or to make an incision. If I were to make an incision, I would make it, uh, let's see, right. There Sometimes it might be easier by putting the suture out here, you see, you might be ending up putting the suture here. So what you might want to do after you're done putting your loop around is you grab the peritoneum here with your Maryland and pull up on your loop and then move it from here to there. Once a year and they really need pediatric surgeons to go teach there. So my lecture was supposed to be on Pediatric hernia repair and I said, let me start off by saying that you guys are doing your operations wrong. And I said, and I said, you know, just to get them going, and I said, let me show you what we do. They, every one of them, I thought they were gonna just tease me and laugh me off the stage. They said, we are in now. We'll start today. Because have you ever seen, I mean, it's a whack. The laparoscopic adult hernia there's a whack. And they're pulling this and they often grab the mask and they don't care because they're like 60 years old, so they're like, well. But that, but, you know, and then they put the mesh in and it clicks or whatever, you're packing it and it's like, oh my God, so this is. I can't imagine the recurrence rate's gonna be substantially different. It would be for a big hole, but for a interactive, and it's eliminates all of their biggest problems that they were saying last night with their pain and all that stuff, so. He's alone. And by the way, there, I That's a, what do you think is the recurrence rate? What do you guys quote as your recurrence, you're not your recurrence. What do you quote is your incarceration rate for like a, uh, a baby hernia? Yeah I always say 30% at least to Jack Langner's uh data and then, but what do you think the recurrence rate is in adults according to the VA cooperative. The I keep seeing her incarce studies made it very safe 1.7%. That was that that was the the paper was, uh, 1.7%. Address what? Oh. So yeah, so the virtual show is coming to a close, um, but we have Matthias Bruzzoni. Hey, Matthias, can you hear us? Let's turn on his audio you have him. Push your microphone button at the top there above the arrow. Um, and then, hold on, we're getting your audio in. Can you say hello. Not yet. Keep testing with Mark, and when, when your audio comes through, I'll turn things over to you. Um. So yeah, asymptomaticism there I think, I think I got it there. I can hear you perfect. All right, so um I can, I can hear you now, but I'm gonna echo. All right, so Mathias, I'm gonna turn this over to you. I wanna, um, just let everyone know that Mathias is gonna talk about the seal approach, which is quite different than mine. All of you guys can, can continue to talk for a few minutes, but then they're gonna have to go to the other room. So maybe in my. Uh, 10 o'clock. Oh, no, no, not this OR. This OR, if you are at 10:01, they're gonna decapitate you. Our OR runs like a machine. It's very bad. Um, so, um, I have time. So we're gonna, Mathias is gonna talk a little bit, then we're gonna take a little break. We're gonna move you up to Another conference room where we can uh watch the communicate from the OR. So, um, for all of you, we're virtual. Thank you for joining us. If you ever want, if there's enough people that want to do this again, I think it's perfect to have a small number like this. We can do another little mini, uh, thing like this, uh, with more microphones, and, uh, thanks for joining us and have a great day. OK, so Matthias, over to you, buddy. Great, thanks, Don. I, I was just gonna show two videos. I have a, a boy and a girl, and, uh, I was just gonna go over the technique really quickly because we, we modified it about 4 years ago, so I, I just wanted to, you know, share with you guys, see what you thought. Um, yeah, let's, let's do the boy first because I, I, I show more of the outside technique also if you don't mind. All right, thanks, doc. like sandwiches. We're all set. OK, hi, good morning, everyone. Uh, now, can I pause this, or, or, uh, you do it, let me see. Oh, here, I got it. Yeah, no, so, um, I'm Matthias Brusoni. I work here at Stanford and, uh, we've been doing the seal technique for many years and, uh, about 4 years ago, we added a little modification and, and try to replicate what a suture ligation of the sac would be but just percutaneously. So these are two videos. One, one's, um, on a boy and the other one's on a girl. So I hope I can show you, you know, what we do and then, um. Uh, see if there's any questions or any ideas that we, we could use to improve the technique. Um, so this is about a 6 month old boy and as you see, we start with a trans umbilical incision with a various needle creating pneumoperitoneum, and then we insert a 5 millimeter step trocar. Um, we put the baby in Trendelenburg and that tends to reduce things, not in this case, but you can see how there's a right-sided hernia with bowel in it. On the left side, there's no hernia. In, in boys, we always make a stab incision on the left flank in order to assist with the repair. You got to get the vest deference and the gun out of the vessels out of the way. Um, and I usually use a, a needle driver. It's pretty blunt and, and easy to work with. So there we are reducing the hernia. And we, we're going to start sorting out the anatomy here. So there's the deep inguinal ring, and under direct vision, we, we palpate it to see what's going to be our best spot for the stitch, and we go just lateral to the ring. And um We made a 2 millimeter stab incision right at the deep inguinal inguinal ring, and this part is very important to create a subcutaneous pocket almost deep to scarpa fascia would be ideal in order to bury our knot once we tie it. So there it goes. That's a CT1 needle um on a 20 Fhebo suture, and uh this is the pass. So the first pass goes right through the middle of the sac, just like a suture ligature would do. And as you see, we get the tissue right past the vas deference and right lateral to the epigastric artery you can see on the top there. Then the needle comes out and before the the swage of the needle comes out of the skin, so right after it comes out of the fascia, we backhand it back into the original insertion site. So both threats are on the same site. Um, of the incision. The second pass now encircles the neck of the hernia, so this is the more difficult pass. So as you see there, we're trying to get in between the peritoneum and the gonadal vessels, and that's usually doable. There's, there's a plane. Uh, it gets a little more sticky on the vast deference, so most of the times we tend to skip the vast. Sometimes we can get away and, and get right in between the peritoneum and the vas deferens. Um, I don't know, we always worry about strangulating the vessel, so we tend to skip it. And as you see, we're going to get the tissue right in between the gonado vessels and the vas deferens and come out with a needle. Now we're going to skip the vast completely, and this leaves about a 2 millimeter gap. And again, we come right next to the epigastric artery. Um, because if you don't, then you leave a medial defect, and that's where we see the recurrences. So right shaving that epigastric artery is ideal, and you can really see it. And this is the 2nd pass, and again, the switching of the needle right past the fascia gets backhanded through the insurgents side, and now you have a full suture ligature. Before we tie, we're going to look on the inside and you can see the two passes here. So the first pass, as you see on the screen, goes right through the middle of the sack, and the second pass encircles the neck of the hernia, skipping the vast deference. Then what we do is we exciflate the abdomen and the scrotum under vision so that way there's no air trapped, and we put about 8 knots on the suture. This ehebo tends to slide and get unraveled, so, so we tie them pretty tight, about 8 knots, and if you had a good pocket, once you cut it. It just pops right in um under the skin, and it looks, it looks pretty flat. And then we insufflate again to make sure the repair is airtight. And uh that means we're happy with the repair. Uh, we, we've been doing this now, doing ileo inguinal nerve blocks under laparoscopic view, as well as a tap block, transversus abdominal splain block, and we do that bilaterally for pain control, uh, and we have pretty good results with it. You can see where the stab incision is right there. That's usually at the level of the belly button. That's where we do the, the tap. So it's basically the umbilical incision, the needle hole in the right groin, and the stab incision in the left flank for the repair. So this isn't boys. Um, I know, Mark, if you want to load up the girl, which is, it's very similar, it's, it's just easier. And there's audio on this one. You can turn the audio off if you want on the girl. The is created. A 2 millimeter st decision is made overlying the overlying the the audio off now? Yes, huh. A subcutaneous pocket is created circumferentially with a hemostat. So same thing in a girl, we create that pocket, a dual polyester suture and a CT1. Can you hear me, Mark? Pa percutaneously through this incision. The needle is passed just superficial to the peritoneum around the internal ring, OK circumference. Um, I just did here just by going down the hall, but, uh, the needle is then passed into the plane. OK, we'll, we'll let it, let, let's let it play. It says it's the exact same thing I'm gonna say, so. Once the swage of the needle is above the fascia, it is passed retrograde through subcutaneous plane to be removed at the initial incision site. A second pass is then made around the internal ring in a similar fashion, but this time the entire hernia neck is encircled, including the round ligament. Once again, the needle is brought partially through the skin just lateral to the epigastric vessels. The suture ligature is demonstrated in a laparoscopic view. The suture is tied with 8 secure square knots under telescopic vision while compressing the hernia sac. I, yeah, sorry about that. I lost you. But I think that that played completely, didn't it? Yeah, so there's a few questions on the chat there, um. Are these people also listening on the mic, or I just have to type back? There, there's, there's um, there's a chat saying since you're incorporating a lot of fascial tissue with this repair, do you worry about illinginal or ileofemoral nerves? So, so we go right on the ring and usually the nerves come, come more lateral and we haven't had any um chronic pain issues postoperatively. Of course, most of these patients are babies, uh, but we've done about 12 or 13 year old boys and girls, and we haven't seen chronic pain issues. Uh, instrument is essential in all cases or only the ones that have like a, a little flap of tissue covering the whole. Yeah, you can get so in girls, you don't need it. Usually the visualization is just perfect, you know, that second video had no instrument and that's pretty much 90% of the cases in girls and boys, I would say. It's safer to have it, but sometimes when you see that um Gnado vessels and the vast deference are right next to each other, that we see, we see that every now and then there's no bridge in between them, then you can get away by skipping both the Gnado vessels and the vass. But I've seen that if you put a grasper and you really think they're stuck together, once you put the grasper, there is separation between them, and, and it's just, I think it's a better idea to get the tissue in between them to, to make almost like a full circumference closure. Otherwise, you might be thinking there's no tissue, you skip it, and then when you tie, you're leaving a pretty big gap. So it's a stab incision with the needle driver. It goes in very bluntly, and we haven't had any issues. I, I, I think it's a safer way of doing it just to, just, just to make sure you get enough tissue. Being in the left flank or do you always, or does it depend on the side of the repair? No, no, so the instrument's always on the left flank. When you repair a left-sided, so I'm gonna say the right side of hernias are more difficult to repair, and the reason is that you go from lateral to medial on the right side. So just like you saw in the video, you have to come right next to the epigastric artery and shave it, but from, you know, coming from lateral towards medial, and that's a little bit hard. Because if you don't shave it, you leave a medial defect that that stays right there next to the epigastric artery, and the hernia comes back right away. On the other hand, on the left side, we still stand on the same side. We always go on the left side of the patient, but now we suture from medial to lateral. So you start by shaving the epigastric artery first. And then doing the exact same motion. So a left hernia, and they're less common than the right hernias, unfortunately, it's easier than the right sided hernia. Side of the bed if it's more common and it's uh you feel like it's an easier and better repair. Because then you have to do it with your left hand. If you, if you can do it with your left hand, that's fine. Or you can turn, uh, and put the monitor up in the, you know, at the head of the patient, but I don't know, we just got used to doing it always from the same side. We explore both sides from the same side, and, uh, we just got used to doing that right sided that way because you can really advance the camera and get right next to the, um, to the epigastric artery, so. Um, yeah, I guess we could do that. That's a, that's a good point. I never really thought about just switching the monitor and just putting it up above the head and, and stand on the feet of the patient. Um. I'll try it. We, you know, for about 10 years now, I haven't done it, but I think it'd be a good tip. Right, so that's the way that I've been doing it. I've been doing medial to lateral for both sides. So, um, so I'll actually scan on a patient's right side for a right hernia, left side for a left hernia, and it, it seems to work really well because I just, I had trouble making that turn to get up lateral to the epigastrics. So, um, so the way I fixed that was just going medial to lateral with my needle. He's gone now. Can you hear me? There, can you hear me? 00, so, uh, say, so how do you, when you stand on the right side of the patient, is the monitor towards the feet or towards the head? Shit, we have 2 monitors, one on each side of the patient. Head and feet, and feet, yeah, kind of left head and right foot and then uh you stand on the patient's foot or or still on the patient's right to throw the stitch on the right side. Patient's right kind of mid-thigh or so, but is your body facing the head of the bed? Yeah, my body's facing the head of the. Oh, OK. All right, so you really turn and the suture away from you. Tempted to just take the epigastrics and I thought that no, that's a good idea. I'll try it next time. Actually it's a good idea. There's a few uh questions here. It says, um. up Can scroll there. Oh, here. So how many cases in the past 4 years and recurrence rate? So we just sent an abstract to IPEG uh with about 210 hernia repairs in the past 4 years and we had 1.4% recurrence rate. Um, which is less than the recurrence rate we've seen just with the one pass, which is about 2 to 3%. And then it says, how about placing the grasper through the umbilicus besides the camera. There was a paper from China about that. Uh, yeah, that's, that's also doable. Um. I mean, you'll be working in line with a camera. You, you, you want, you know, good visualization and be able to use that grasper as, as best as possible so the stab incision still works and, and, and you can, you cannot see the scar postoperatively, um, but yeah. I want to thank everyone for attending the event, Dr. Brizzoni, um, really thank you. We're going to have to conclude now because we have to go watch the live cases. But again, everyone, thank you very much. Um, sorry about the few audio glitches, and I hope to see everyone at our next event. Have a good morning, good afternoon, good evening. What time zone you're in.