All right, so let's see. So while placing a laparoscopic G tube, you happen to turn the scope around. By the way, does anyone turn the scope around when they do a laparoscopic G tube? Yes, yes, I stopped. OK, I stopped, and you do it to look for hernias. I know you do. OK, we just do a CT scan. I'm telling you, man, We, we, we get an MRI. All right. So you turn the scope around. Uh, let's start with Dan. Oley. You can hear me, buddy? Unmute your phone. Yep. All right, man, you put in a scope, you turn the scope around, you're doing a lap to YouTube, do you repair it? Uh, yes, at a 4 year old, I would. OK, laparoscopically or open. Clap. OK, uh, Sean. Yeah. Open or loud? I, I would actually not repair it. I would talk to the family about it and fix it at a later point. Got it. OK, so faculty here, let me just ask it this way. Is there anyone that would repair this? Yes, laparoscopically. Yes, laparoscopically. I'd get consent. You walk out of the OR, go talk to the family, and you would do, OK, so it's so funny that you guys say that because I know. You know, Dan, it was the same conference where we did the TPA thing where I was the only person in the room that said that they would have repaired it. So since then I've changed my practice. So now you're making me change it back again. But right now I don't, I don't, I don't do anything if I happen to see it at that time. So don't look. I don't look. OK, I don't look. So and the only time I would look is if I'm doing an app because I'm in that area and I'm definitely not going to do it. So any comments about that before we move on. Then what do you do? I mean, you've seen it. It's a good one. So what do you tell? Hold on, Sean, one second. What do I tell the family? I say, I say your child has a patent prosthesis vaginalis. There is a, they have a 4 times greater risk than the general population of having a hernia at some point in their life, but they may never have a problem. If they do, we can go ahead and do it and fix it. And the reason is the person who convinced me was wet. And Witt's argument to me was he does not believe that a hernia repair is the type of conversation you go have quickly in the in the waiting room with a family because if there were some injury or whatever, that was kind of a rushed conversation about something that they may never have a problem with their entire lives. That's what made me change my practice. I may change right back again, but right now that's what I do. Any, Sean, yes, or Dan, Dan. I would totally agree with you. You just said. I misunderstood what you said. I would not repair this at the time of the G tube, but I would electively repair it later with the family. Oh, so you would do a second operation? Yes. Would anyone else do that? No, as long as it's asymptomatic, I would, I wouldn't do it. I wouldn't do it. If the, if the child is over 5, because that's the number I've picked for my entire practice is 5 to stop scoping the other side or anything else, I wouldn't do anything to it. But if a child's under 5, I just, the argument is that it hasn't been there long enough to show up and. Right, wrong or indifferent, that's what I do. OK. But you, you know, Dan, you make the, you, you asked about contralateral exploration. It's like if you're not going to fix this, why do contralateral exploration and fix that? I don't anymore. But I, but I do. But so my argument would just be the kid's proven they can make a hernia. Scott Bollinger said a great comment. He said, Why eat tomorrow's lunch today? So you can make the argument and come back another day. Um, OK, uh, ironically, I'm totally hypocrite because I do these laparoscopically and I always consent for left and right. Now that's a pre-consent though. I say, do you want me to fix the other side if I find something outside? And every patient I've ever had has said yes. So it's that same argument, it's not too far to extrapolate whenever you're doing a G tube that we're going to look at the groins. If we find hernias, we're going to fix them. So then you have to have that conversation with every G tube and pyloric. I mean that's the question. I think if you have the discussion ahead of time, it's worth it. OK, so actually, sorry, let's do this. So, uh, can we just pull the audience real quickly? Oh, it was out there. OK, good. So it looks like 44% would close and tell the family that he is an increased risk for a hernia, 33% would do an open repair, and 20% would do a lap repair. Interesting. OK. Uh, just say, uh, let me, how can I put this? Um, I'm assuming you would do a high ligation in this boy. Is that correct? Is there anyone that wouldn't? OK. I'm gonna keep going. I want you to tell me when you would stop doing a high ligation. This is for an indirect, for an indirect inguinal hernia. So everybody here would do a high ligation in all of these patients. Nobody would refer this patient. Let's see, do I even have a, no, no one would refer this patient for a mesh repair. No one would do a mesh repair, tap or tap. No one would do an open, an open repair in this chap. Actually, that's not true. Let me, no one would do a different type of maybe add a little muscle repair to this, no. Would anyone refer this patient to an adult surgeon? Say he's 18. 20. I, I now go up to 50. Well, I'll do any age too. So I feel strongly that a patent process of vaginalis is the same as when your day of life and the end of your life. A day of life one and the end of your life. I think if there's a muscle problem, that's a different type of hernia. High ligation is the appropriate repair for any age, in my opinion, and give me some time and we'll find some. Yeah. So I totally agree with that statement, but then there's the classic. Resident dilemma. Well, can you tell me it's an indirect or direct before we operate? that's great. So what do you do with a 3 year old's got an indirect hernia, I'll do, OK, let's take 2, let's take 3 questions out of this quickly, rapid fire. How do people examine for a hernia? In this, in, in these patients, or does it depend on age, do you feel in the groin? Do you put your finger up into the canal? You go by history. What, what do you, what good exam do people do for a hernia? Yeah, all the above. And how accurate do you think you are with the putting your finger up in the canal? Pretty good? For what? For determining direct versus indirect or whether there's a hernia? Both. Let's take, let's take first to determine if there's a hernia. Do you think, do you think you're pretty good at diagnosing a hernia with that technique? You talking about a baby? No, you can't have a, I'm talking about a child that's old enough to cough for you. Pretty good in an adolescent, I think it's pretty good. You have to stand up strength. It was interesting. That's how, go ahead. I, I was gonna say that I always thought the finger up the, the, the canal was worthless and just tortures the kids, um, and that you can feel better with your hand, fingers over the, over the area of the internal and external ring, and you can feel that pop out just like you do in a baby. Uh, maybe if they're really obese with a big fat pad, maybe you need to do something more, but I would just I would just feel on the outside, and that's all. I do I do. Somebody's got their, either Dan or Sean, I don't know if your computer speakers are on here. Yeah, so I was at this, the Sage's hernia course and I asked all the adult surgeons how they examined the hernia, and not a single surgeon in the room dug up the canal thing. They all did, so I changed since then. It drives me crazy when I see this because the residents will do it and then and then the kids, like, like as soon as you go to examine them, they start cowering, right? It's like it hurts someone tweaking your backs. And then your other question you were asking, just, I mean, do you know? I can't tell the difference. I've never been able to tell the difference. You can't study has been done and personally for me, I don't feel as facile with the more complex floor mesh repairs. So if I think that's a Maybe a confounding piece. You'll send it to an adult surgeon, but I have no qualms against doing a high ligation at any age, even if someone's 80, if they just have a if they have a patent prosthesis. So that's all they need. So what would you do if you went in and you thought it was an indirect and uh and it was a direct hernia? Would you, what type of repair would you do with your skill set? I mean, my skill set, which is people, I mean, I would do the traditional muscles. That's what I would do I should kind of are you How are you getting referred a 30 year old. To get the basics, let me explain. You're going to be referred to 30 or 40 year olds, and if you do that in a big medical center, a big hospital, are you going to be prepared to have the general surgeon shoot you with a gun? So Dr. Corn, let me answer your question first, so. The highest I've ever been referred, I think is a 20 or 21 year old. OK, OK. The reason I'm telling you about my experience in adults is because we now have a prospective trial in an adult institution studying high ligation alone in adults. We've done up to 80 years old, so that's not my patients. But that's what I would, yeah, that's my belief that's a different story. So point of view of, you know, what do you do with these cases? We don't see you're a 30-year-old elective hernia, because, you know, the reason we got to all this, if you look at it historically, the first operation for hernia repair was herniotomy. You know, you take a shot of whiskey. And you bite the bullet and they just cut it open and with that 70% of the time it actually worked, but there was a 30% recurrence rate and then what happened was is that Ladd and Gross went on and started doing high ligation. And the adult surgeons all thought it was a floor problem, so they started taking the floor apart and putting it back together and doing Muccini and McVeigh's, which have a 10% recurrence rate. And then you had Liechtenstein who came in and got it down to 1%. And so they were responding to different problems, but they never addressed the underlying pathophysiology. I think that pediatric surgeons and adult surgeons diverged at some point. But now you know you're trying to bring it back together back together, but I think it's great because I think that, you know, the high ligation is a very simple operation whether you do it open or laparoscopic, right? Let's go on to the next slide. Let's see if my clicker works here. So through these. OK, six year old with a reducible left inguinal hernia. How would you repair it? Open? Trans umbilical laparoscopy followed by open, open repair with laparoscopic look on the other side, intracorporeal laparoscopic repair or a percutaneous laparoscopic repair. Anyone to define your terms, OK. I mean, what's a, what's an intracorporeal lap that you're talking about putting having two instruments in and tying talking about suturing on the inside, the purse string versus the percutaneous versus the percutaneous extracorporeal operation. You don't have mesh repair. Right, you laugh, but unfortunately, I see, I've seen a few patients who were seen by, you know, adult surgeons who have done mesh repairs in, in, uh, yeah, I don't think that's, then I get to go back and take out the mesh and. Um, OK, let's see what our results are. 70% do an open repair, 27, 25% do an open repair with lap look, and only a tiny percentage. If I could click, I look like the only one that no one clicked here, and I know of several of us on the panel do this technique, which is the last one, which is E, percutaneous laparoscopic repair. Who here in this room does the does a laparoscopic? So one. Laparoscopic 2 against the terms. It's the well, let's first do lap because then I'm going to break it down. Who does lap 123456 and the babies if they're older than a year. I'm putting a camera in and you're going to repair it laparoscopically. Yeah, OK, now we're breaking it down. So among us, who does it intracorporeal with suturing a purse string. OK. You started that way and you switched, right? Yeah. And now who does it percutaneous, so we all do it percutaneous, OK. Um, and the reason is so. Uh, Mark, we roll this video, but I don't do it at this age. I still tend to do it over at what age? Like 6 years old. I'll do it because I just feel I'm I'm faster. OK, well, I give the parents an option. Mark, you can skip it. That's, that's what I give the fellows an option. Yeah, I give, I give the parents the option, but I'll tell you, you know, so what's interesting is, you know, you know, I demonstrate. Go ahead. You can play it. We'll play it 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 prolene 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 hernia. And because we prefer to use an ethebond suture at the end because it's a softer knot and it works better, we then exchange this for an ether bond, cut the ends off, and we do the ligate. And here we're going to show it in a couple of examples. So this is the first case. Here I line the tips up and I put it through the tip. The two ends come out to the back as you can see, and then I pull the loop and I pull the loop just till it stops at the tip of the needle. If you pull it too far, sometimes it is a little difficult to advance. Then I inject marcaine into the inferior portion of the umbilicus, and I usually use a 3 millimeter camera, but this is an extra 3 millimeter. Maryland dissector that I put in through a stab incision. No matter how large the patient is, I always use a stab, and we do this because in our study in rabbits, we found that in the rabbits that we caused injury and then did the repair. It was much more durable. In fact, even if we cut out the stitch after 12 weeks, the closure remained intact. So, the injury really keeps things closed. So here you can see the cord vessels, the vase, and the vessels. Then we find exactly where we want to make our incision in the groin. The incision is ultimately going to be the size of a needle, but to find this spot, we're looking laparoscopically. We match up to find the 12 o'clock position on the outside, and then we make a 1 millimeter nick with a knife just enough to get the tip of the needle through. Then prior to doing the repair, I hydro dissect with buppivacaine. I usually use 0.25% or 0.5% if it's a larger patient. This dissects the cord structures away from the peritoneum, as you can see here. Sometimes if it's a very small patient, I may even dilute out the Marcaine so I can do both sides. It's a bilateral hernia. Then I take the threaded 18 gauge needle and I pass it first laterally. I, you can see here that I'm clearly dissecting above the cord structures. I'm always standing on the patient's left side, left side facing their feet. I have the monitor at the foot of the bed. That's whether it's a right or a left side hernia. I always Stand that way and I always go lateral to medial first. Here you can see I'm clearly above the chord structures. I usually stop just short of the vas deferens when I'm going from lateral to medial. Then I thread the loop through. And I pull the needle out. And then I secure that with a hemostat. You want to make sure that if you push the loop through the needle, you don't pull it back into the needle because then sometimes it's hard to push it back through. You want the loop just at the very tip of the needle. Then I go immediately. I will use the Marylin to help me give tension on the peritoneum. And you can see here that I keep making sure that I'm above the vase. If there's any question, I will skip out over the vase and leave 1 millimeter of tissue. I think that that is not a real problem to leave 1 millimeter of tissue. That needle goes through the first loop, and I snug the first loop around it, and then after it's snugged around, I push the thread through the second needle, through the needle. Then I pull the needle out, so now my second loop is threaded through the loop of the first loop, and I pull that first loop up like a snare, and it pulls that second prolene all the way through circumferentially. So now you have looped proling all the traversing all the way through. Now you could be done and just tie this down, but I don't like the thick feeling of of the knot of a proling. The patients complain. Plus we've shown that when we use a braided. Non-absorbable suture. The repair is better, at least in rabbits. So once we've got this around, we will exchange the prolene for an ether bond. You do have to start with a prolene because the ether bond is not stiff enough to be threaded through the needle. So we do this and then just do a quick exchange at the end. Like I said, you don't have to do this, but then you just pull it right through. It takes just a minute. You do have to evacuate the air out of the scrotum, an inguinal canal prior to doing this. So I usually have an assistant push down and then I cut the Ehebo, which releases the prolene. And now you have the 3 ends of the Ahabo suture. You can use silk or Ticron. Or any suture you want. I do think you need to use an um a non-absorbable suture. Um, although, like I said, if you had injury, you may not even need to. Then I cut this right above the knot. And I usually put about 4 or 5 knots in. On each and then I pulled the skin. So that's a double ligation actually because we've looped it and cut it. And then here you can see that the core structures are well away from the repair. So I would say, so I use, you know, my open repairs, I always use PDS and so I use PDS on this, but I do your injury thing. I do the cautery. So you're doing the study for us because we're doing, we're studying that in rabbits to see now that. If you cause injury, you probably don't need a non-absorbable suture and so we probably don't need to do a rabbit study because you're doing it in humans because, because what I, what I worry about is, uh, I mean, for those of us that are old enough for when the reason people use Vicryl or PDS on, on open hernia repairs now is because There was a generation of us, and before you spent a lot of time picking out silk sutures, spitting out of the groin or abscesses that would necessitate up the umbilical, the umbilical ligaments years after you put them in right to the to the umbilicus and I worry about your, I worry about your, we do too. That's why we're trying to move to absorbable. Quick question. So high testicle, you can pull the testicle down and it stays there. So, how would you manage this retractile testicle? Anyone here, so would you reassure the parents with no follow-up, reassure the parents with planned follow-up, but no plans for surgery ever. Reassure the parents with planned follow-up with a plan for repair if it still persists after a certain period of time or repair. Let's see what's polling. Anyone have any comments? What's your definition of a retractile testicle? You grab the testicle, yeah, and it stays down after you let go. How long? long enough for me, if it stays down, I don't sit there and watch it, then it's not. I consider that undescended. I don't keep watching it. I consider that descended. You consider it descend descended retract, retractile. Yeah, I sent him home and pat him on the back. Yeah, I never see him again. Yeah, yeah, OK. Everyone's the same. Moving on. Dr. Corn did not used to practice that way. You brought him back every year because on occasion one will go up and get trapped, one that has been pulled down. It's a known phenomenon. It's been has been reported that a true retractile testis that you can pull down has occasionally gone up. How it gets trapped, I don't know, but it does, you see a few of those, and there have been some reports of that. So I think until they've gone through puberty, I would give them a 2 minute office visit. Every year as Mac knows when he was there. Don't lose anything. It has not happened to me. I didn't see one personally, but it's been reported. Yeah, the reason I put that is one of our former partners also followed them. He, he felt there was a risk of torsion, which I've never. I've never been able to find that. But if you look at the results from the audience, it's different than the studio here, so pretty varied. I think nobody would operate, but uh. With plan, maybe there is 30% say see if still present after a certain period of time, they would operate 30% of the audience. So it'd be interesting to see when like you're talking, when is it retract. I mean, does it, if you pull it down and let go, it goes back to that spot. Yeah, well, Stefan, that's the wrong poll results. Sorry, can you show The one that was just before that, yeah, once they, once they've gone through puberty and the testicle is much larger, they can't retract that. So all you got to do is follow them long enough to be sure they've got a, they're post pubertal and the testicle, a good sized testicle, it's going to stay in the scrotum, but in that period between the time you see them. And the time they go through puberty, there's at least a theoretical risk of them going back up and being caught. They're not a true testicle, but they need to have something done to them. I don't know the answer, but it's always that stage of when is it really if you pull it and it comes down, stay down when you let go. That's simple, but if you get it down, it comes down pretty easy, but you're let go and it kind of drifts back. I mean, it's just windy you say it's, I think if it comes down easily, even if it pulls back, even if it pulls back, I agree. I think it's down. I think if you can pull it down, it's down because I've I've seen people, uh, I mean, I had one kid that I could never get down in the office. I mean, I don't know if you're going to get to this, Todd, but I had a kid that I could not get down in the office. I was convinced it was an undescended testicle. We had the kid squat. We did everything. We in the bath. Mom said it was still up and took him to the operating room. As soon as we take the covers off his bottom after he's asleep, boom, both boys are in the sack, and And so, you know, so I, and I'll tell you that I did you do wake him up. I woke him up and told him, look, this is gonna be fine, but I do know people, and you know one of my partners would have, uh, would have put, you know, done a button orchiopexy or would have done something to that. I, I'd do nothing. What, what would everybody around the table do? I, I would do the same thing you do. I mean, you could, you know. You could probably do a little, make a little tiny schnit on the, on the surface of the scrotum, create a little Dato's pouch there and put it in that. Probably won't hurt the testicle and probably is OK to do, but I don't think you have to do anything. Um, I'm debating if I should even go forward. We still have about 2 minutes left, so let's just do, uh, so what if a child with a retractile testicle also has a hernia? So I guess the question is, uh, I have had this where the scar can sometimes make a retractile hernia scar up in the up position because you're going and you're doing a hernia repair, um, probably not so much, well, it's probably not true to say that open versus lap, but would you do anything different? Would you do a transcrotal stitch if you're doing a hernia repair or just It's a retractile testicle. It'll be fine. Go ahead and do your hernia repair. So if they're under anesthesia and it's a retractile testicle, it's going to be down and look normal. Yeah, yeah, no, no. So it's a patient that has a retractile testicle preoperatively in a hernia. OK. And you go to the operating room, just do a hernia repair. Yeah, but you're going to be able to tell in the operating room whether the gubernaculum is intact and and if it is, then you're done. Yeah, but, but if the totally, but after surgery and after things scar up sometimes. It can ride up a little bit. So I think that riding up is what what happens. I think people, if you're doing an open hernia repair, I think it's getting, getting a little bit of cream master or some of the vessels in the cord stuck in your cot in your external oblique closure if you open external oblique. So you don't think a retractile testicle has any higher chance of high riding after a hernia repair than a normal stuck down. I've seen that once. OK, let's keep going. Eight year old boy with a good history of groin bulge that comes and goes by the PCP but uh and mom, but nothing on exam. So, exam history alone. Good history. History alone from physician and mother would just operate on it, operate, operate. Would anyone not operate until they see it actually themselves or a photograph. When you said operate, did you mean open groin incision? Yeah, I, I, I think it depends on how convincing the story is. I mean, if it's pretty convincing and they can point where you would expect to find a hernia, then, um, and I can't elicit it in the office, then I typically offer laparoscopy. Um, uh, if, if, um, if it's not a convincing story and it looks like it maybe it's just a retractile testicle or something like that, um, send me a photograph or, you know, re-examine them in a month and see if I can elicit it. Actually, I usually point at the suprapubic fat pad, right, right, right, and sometimes it's actually a retractile testicle that goes up into the, but 80, 60% said wait for a photograph of the audience, um. So missing testicle, no palpable testicle. Ultrasound shows no testicle on the left, and you go in and you see it right there, right there at the, uh, it's like a peeping testicle, sort of right there. How would you approach this operatively now if I have choices. First of all, we've never got an ultrasound to begin because you don't have, OK. Right, so, so if there's an absent testicle, you can't, you can't find one on exam. You don't need an ultrasound. You go straight to. No, but if you do, if I do an ultrasound and I don't feel a testicle on exam, but I see a test, I see a testicle on ultrasound, I would do a groin exploration. So, but then, but then why not do a laparoscopic? No, but then, you know, at least Dr. Ricketts would say to me, well then you didn't do a good enough groin exam because if it was in the canal, you should have been able to find it, you know what I mean? I mean, but you know, I mean, that's like classical teaching, right? So who here gets ultrasounds on these patients? Am I the only one here that gets an ultrasound on a missing testicle? I'm just surprised you didn't get a CT. Is that true? So no one else gets an ultrasound. If I, if I can, I can't, I'll put a scope in scope, scope. Everyone would do a scope. No ultrasound, OK. That's it. So, uh, What do we say here? So we're not going to talk about how we're going to fix that testicle. Who would do it right, right, right. So the question is you have to commit. So are you gonna, so go ahead. So you go in and it's right there. Would you divide the gubernaculum right off the bat, or do you, how do you go about doing that testicle there? I'd probably do, uh, I'd do it, I'd do a Fowler Stevens. Well, so I, I, I, I, I would do a two-stage, but I, but I want, I really want to have the You know, not going to, we're talking about to do a one stage because if you look at the data, one stage is probably just as good. Dan, and I have, I just haven't done it. Yeah, I mean it's pilot data, but certainly the retrospective data and the prospective pilot data that we Presented at IPEG this year suggests that one page is just as good as 2. So everyone here would do a follower Stevens on that patient. Where is, where's, I didn't hear exactly where was the testicle when you right at the rim. show the picture the picture. No, this was, this was, this was not below that's not a peeking testicle. That's not a peeking testicle. I couldn't see it, but it's more intraabdominal. The whole testicle is on the abdominal side, but it looks like it's got good size. Now, what if you, what if you did that and it's a little nubbing? What would you do? You mean the testicles it's just a. How old, how old is the kid? How old is the child? How old is he, Todd? 1 year, 8 years old. There you go, 8 years old. 8 years old. So a nubbing might curl a little bit. Hm hm I'd have taken it out I'd have it out buckets as they said it depends on how much of an.
