Jump right into a scenario. OK. So these first few questions really get down to things like the timing of surgery, not so much um, how, how we do it, but I'm happy to talk about that too, because I'm I'm always eager to learn. So this first case is, you know, one of those cases that we as pediatric surgeons consider a big case, right? It's the pre six week old. Premie male, uh, with, um, with large bilateral inguinal hernias, and they're easily reducible, so there doesn't really, it's not like we're dealing with an incarcerated hernia. In this case, the child is 2200 g, 30 weeks premature, but now, uh, close to, uh, uh, gestational age. Um, he's healthy, he's doing well, and the NICU calls you because they want you to figure out how we're going to fix these hernias and when, and they think that the child should be ready based on his current projection to go home in a week or two. So then the question becomes, uh, when, when do you, I think we can all agree that the child needs surgery, uh, for these hernias, but the question is when. So, I'd like this to poll the audience, uh, when do you recommend repair? Uh, do you do it, uh, This week, you know, before they, so that they're fully recovered and ready to go home, uh, at the expected time, or do you send them home and then do it electively, either right soon after discharge at the first follow-up, you might talk about it, or at a certain age, maybe some people have an age criteria, or, uh, do you wait until they can have it done as an outpatient, which at least at our hospital, could be a very long time, 6 or 8 months, but, uh, um, so I don't know. Well, let's, well, well, we're putting the poll up, let's ask the, uh, the panelists here, Dan. Uh, we would fix that. Before discharging from the hospital, hers. Jack, uh, we would fix it before he goes home if he lives a long way away from the hospital, which is a significant number of our patients. But if they live locally, uh, we would send them home and bring them back at around 50 weeks post conception. All that the cutoff for your anesthesia folks in terms of outpatient 50 weeks is what they usually say. All right, Jack, I need to stop you for a second before we get to. So I also thought that I, I also thought, you know, we could Wait, they don't necessarily need to be repaired right away. But then I read your papers about the very high incidence of incarceration in the first few months of life, especially in the preemies. So we were at the Washington DC conference a couple of months ago, and the only people that said that they would wait were the Canadians. And I said, you know, based on the Canadian data. I don't, I, I, I don't, I do try to operate early and they said, I said, who out here doesn't, the Canadians are only two that said no, we do it later on. I said, but it was the Canadians that showed us that we need to do it early. So it sounds like not everyone follows that same philosophy. Well, it's, it's is a risk benefit analysis, right? So if the risk of going at 2200 g and a very tiny baby like this is very high, then I would consider that risk to be a higher risk than the risk of waiting on a kid where if it becomes incarcerated, they can come early to the emergency room. But that risk changes when they live far away because then if they get incarcerated, then they won't be, they won't have access. Fair enough, Aaron. I'd like to fix them before they go home. It gets more convenient for the family. OK. Anyone differ? Anyone have a comment to make in the peanut gallery? No? OK, we're going to keep going then. Wait, do we have a poll result yet from the audience? Oh yeah, it looks like 68% prior to discharge. That's pretty impressive. Yeah, so that we'll get to another question after this one. I kind of went out of order a little bit, but, uh, the Um, uh, because the, there was a study that came out of a multi-institutional study not too long ago, uh, that, uh, the risk of anesthesia for premature infants and subsequent cognitive issues and smaller brain size and white matter that, that has pushed a lot of our neonatologists to be afraid, uh, but we, we could talk about that too. But just out of curiosity, when you, when you, when you repair these, now this is tough because I guess more and more people are doing these laparoscopically. I still do them open, but, um, when you do them open, do you, do you? Some people say you should just operate on, now this one is a bilateral, uh, one, but if it's unilateral, do you operate on the, on, uh, on the other side, or do you laparoscopically, do you do a contralateral exploration, or do you think they're too young for that? Um, just curious what people, uh, think. I mean, it gets a little bit into the contralateral exploration question, but, uh, in the preemies, I think it's a tougher call, I think. OK, so we're, just for clarity to make this easy to ask, for those who don't do it laparoscopically, right, who don't do a laparoscopic repair, who do open repairs. Your question is, uh, who looks on the contralateral side? Right? I mean, or, again, I mean, maybe it's not an important question anymore, but, uh, but I think, I think it is if it's a unilateral hernia, because back, back in the day we used to before laparoscopic contralateral exploration. Uh, became popular and, um, that we, some, some of my attendings who were training me would say, I just always make an incision and I, I do an open exploration of the other side because the risks are there, and others say no, you should never do that because most of the time they don't have one. So Jonah, do we have that poll because if not, I might revise it. If we, maybe the way to ask it is, what's that? OK, here's a question for those who do open hernia repairs, do you do a contralateral exploration? Do you do nothing or do you do a laparoscopic look? Is that a fair choice there? Um-hum. Contralateral, routine contralateral exploration, uh, lap look, uh, or nothing? Yeah, and I had changed that question to include a laparoscopically, not, not applicable because I do laparoscopy, but OK, or not I don't see it up there, yeah. OK, or not applicable, I guess you could add that too. So we'll put that up there and we'll wait a minute or two. We can keep going and we'll see those results in a few minutes. Um, well, let's ask the audience here though, um, just rapid fire. So what's your, do you, I would stick a scope in and if I can't see easily, I would not do anything. Let me clarify, you do it open, open and you stick a scope through the sack. Put a scope through the sack. If I can't see easily, if I'm worried I'm going to tear the sac or it's a tight opening, I just do. OK, Pete, what do you do? I do the same thing. So I, I would try to put a scope in if I can. It gets tricky because these hernia sacs, as we all know, are extraordinarily flimsy, and if I think I'm gonna tear it, I just leave it alone. And if there's nothing to suggest a hernia on the other side, then I would just leave it, leave the other side alone. Jack, I fix what's broke. OK. OK. I do. Good answer. OK. Uh, So, I do a look at the other side and if there's one there, go ahead and fix it. OK. All right. So, I've modified. I do, I, I do open. I do bilateral up to each year, and then I go through the belly button from 1 to 6. Now let me make a comment on that. Is that, um, you know, Rothenberg does a lap look, but he puts a needle in the abdomen directly in front of the contralateral side because he believes coming from one side looking to the side, you cannot get an adequate look because you might have a little flap and it looks like it's not a hernia. So that's why I gave that technique up. That's an interesting point, Mark. Yeah, I did the same thing. I go through a small trans umbilical bars needle approach and look from. The center point confirmed hernia on one side, which is usually the clinical diagnosis, but then you can sometimes you follow those sacs in and with an 80 degree or a 70 degree scope from the contralateral side, you like Doctor Van Allen said, you just cannot see. So with the 30 degree, I can always tell, and you can even march that scope down to the sack a couple centimeters. Oftentimes it's just a blind wait, wait. OK. And then, uh, Tim, yeah, I do open lap look, but I don't. Try to be aggressive looking to tear the sack, so I just, I can't see anything obvious, I don't do it. OK, Jose. I, I do open and I do it for boys and I do a lap look and uh. I, I worry a lot less about tearing the sack after having learned from you in the past that a large part of our colleagues in the rest of the world don't close the sac routinely. We, we won't get to that later, right? And just the answer is that I do it laparoscopically, so I, but can I just point out that that when you see a patent prosthesis with your scope, there's only still a 20% chance that that will ever be a clinical hernia. So you are, you are handling the cord in 4 out of 5 kids that didn't need it. Point taken. I didn't know it was that low, but, but you're right, it's not all of the ones with the patent process have a hernia. I heard 4 times greater risk of having a hernia if you have a patent processes vaginalis, which is another way of looking at the data. 4 times. Say that again. You have a, if you have a patent prosthesis vaginalis, you have a 4 times greater risk than the general population of having a hernia on that side. So if the general population incidence of an inguinal hernia is what, 7, like 2 or 3% or I don't know what it is, you have 4 times that risk. So the real, the real question is what's the, what's the risk that you're going to develop a hernia if you have a patent prosthesis, not compared to the normal population, but compared to the population that has a patent prosthesis because that's that's that you're, you're unnecessarily. Unnecessarily closing if only, what did you say 1 out of 5 it's about 20%. Yeah, 1 out of 5 of them actually develops a hernia, then 4 out of 5 get an operation they don't need. Um, Witt has a comment and then we'll get Pablo Laje has a comment as well. Well, I think, I think Jack has a very good point. So I actually give the family a choice. I tell them that there's about a 20% chance. Of having a hernia, a symptomatic hernia on the other side, and if they want us to scope, they can. If they don't, that's fine too, and do whatever they, they wish and so involve the family in that decision, because I don't think there's a right or wrong answer in this. It's what the, if the family, it's really what the family wants as, as long as they understand the, the odds both for and against the, the need for another operation. OK, um, Pablo. Yeah, I just have a simple question. Uh, I wanted to know until what age would you do or offer to do, uh, uh, contralateral exploration with any laparoscopic technique. Uh, we sort of came up with a completely non-scientific cutoff of 8 years, um, but I know that if a hernia has not been symptomatic by then, it's unlikely to occur. Um, but at a younger age, we tend to do more and more exploration. So is there any age beyond which you wouldn't do the laparoscopic exploration? Yeah, that, that is a difficult question and a good question that we were gonna get to, but we can, I'm happy to talk about it now. Um, is, is there an age cutoff? I mean, uh, there, there are studies that suggest that there's no difference based on age. Uh, there's just, they're just as likely or unlikely, I guess, is more, is more like it, uh, to have a hernia or a patent prosthesis, and, uh, um, but, uh, but I don't know, it's, there's a, it's a perception, maybe a false perception among most of us that it seems like the younger kids are more likely to have it, but maybe because we're looking more frequently, I don't know, so. Does anybody have an age cutoff for when you explore for those of us who do a contralateral exploration, so I do it under 5, and between 5 and 10, I'll look at the body habitus because I don't think, I don't want to do a, a contralateral exploration if the child is hefty and it's a very small hernia because that's not likely to be so traumatic. And then I don't do it after 10. So between 5 and 10, I base it on the child's body habitus and also discussion with the family. Does it matter if it's a boy or a girl or whether it's left or left sided or right sided or whether they're a former preemie or anything like that? No? To me it's the difference of whether they're a former premie or not is significant. So I don't. Typically I just fix the broke as you said, not on a term. Older on any child, 2 year old, 3 year old. So the only thing that I can tell you is that Jack's data shows a very high incarceration rate with newborns and preemies, but the VA cooperative study in adults had a 1.7% incidence of incarceration in adults that have an inguinal hernia. So the, the chances if they've gotten to a certain age over 5, the chances of them ever getting incarceration is almost none. I mean, it's 1.7%, so it's pretty low. I think, I think the statistics are 80% of kids that are going to be incarcerate are under 12 months. Yeah. So I, I use a year personally. So if they're under a year, then I will scope in and look at the other side. If they're over a year, and especially as they become ambulatory, and I figure it's also more verbal as the years go on. Um, it's a little easier for parents to feel comfortable that the child will complain about something if it develops and that you can treat it in an appropriate time. So I think the answer is there is no answer. I mean, and I, and I thought reviewing the literature I was going to be able to figure this out and answer it for myself, uh, but the truth is it's really difficult, and part of it depends on the country you're, you're, you're, you're, or the institution that you're working in, and that that may have something to do with cost, um, but, uh, and, and there are people who come up with the same numbers, like a 5% chance of, of hernia of contralateral. Hernia and some say oh that's too high, we should do an exploration and others say that's so low it's not worth the exploration. So it's even not even just agreeing on the data but agreeing on the interpretation of the data. So, uh, it becomes tricky. So, um, but I, I generally up to, up to, uh, about age 8, and it's an arbitrary number I admit, uh, will talk to, I talk to every family about it, and some of them will say yes, let's go for it. Most of them, because I probably because of the way I couch it as being safe and easy and simple, but, uh, anyway. But then the other question about the before we move on from this preemie is the timing of it because there, there's been a little bit of, there's been a lot of anxiety on the part of our neonatologists. We recently had a, a patient come out of the, the NICU or come back with an incarcerated hernia who had been discharged from the NICU even though our. Our, our standard protocol, we thought it was a protocol was to fix them before they go home, but that was because the neonatologist on duty said, no, this, this new data suggests that it's dangerous for preemies to have, uh, to have general anesthesia, and they can have neurocognitive deficits down the road. And so I think it's thrown us into a little bit of a, a difficult spot because we don't know how to, whether we should be reassuring them or saying that there's not enough data yet, but I, I'm just curious if anybody else has had similar anxieties expressed to them either from parents or from neonatologists about the, about the risks of general anesthesia in a preemie. Yeah, yes, um, so not from the parents so much as our anesthesiologist, uh, not at this institution, but my previous institution, um, were very concerned that we were doing our hernias too little. They wanted us to wait and we were weighing the risks of incarceration versus neurologic impairment, and, um, we never changed our practice, um, because I wasn't, I wasn't as familiar with the data. And I'm not sure anyone is. I'm not sure, but I think it's something that we will be looking at in the next 5 to 10 years, and it may adjust our practice. Yeah, I think that I happen to be at a national presentation by an anesthesia group and The, the feeling there was that the data is so immature right now that it's really hard to tell what the risk is and whether it's impacted by the duration of the case or the age of the child. There's so many factors in there that nobody really understands. It's very unclear what, if anything, is the risk of anesthesia. Yeah. Well, I, so I would agree with that. I, I, I, I'm, To hear that no one, we don't know yet, I guess is the answer. So I've had family, I mean maybe in the New York City area, I've had families who've approached it with that question, and I've just answered honestly that we don't know and that most of that data is from animal data, not, not from human data, and that therefore I don't know that you can directly extrapolate it. Well, it's like every other week whether you should drink coffee or not, you know, it's either beneficial or it's dangerous. So we'll see. Hopefully we'll get some more clarity as time goes on. Um, so the second case, let's see if I can go back here, is a case of an incarcerated hernia, a fairly straightforward incarcerated hernia that's reduced in the ER with some difficulty. The child vomited once but is not overtly ill, and then once you, once you reduce it, the child is back to his normal, normal activity. So I'm trying to go back. I don't seem to be I think it's frozen a little bit. Mark, can you go to At the beginning, we have to go back. I'm having trouble on Adobe getting it to go back, so maybe you can do it. So the big question is, because we, we, we have a little bit of uh a difference of opinion among amongst our group is when do you fix the incarcerated hernia that you've been able to reduce. Um, and so there's a poll question that I had and I think one of them was to operate on them right away. And see if we can go back, it should be question 2.1, I believe. There we go. Discharge them home and have them follow up in the office? Do you do an emergency hernia repair either that night or first thing in the morning? Do you admit them for observation because you're concerned about, having reduced the necrotic bowel, uh, or do you watch them and advance their diet and if they do fine, then, then discharge them? So Jonah, let's put, put up that poll, and while we're polling, let's fly through the, uh, panel here. Uh, Dan. Um, I guess it's hard for me to uh give you one answer to that because it depends on the patient, you know, if the patient, if it was very difficult to reduce and it's an ex-preemie and they're, uh, potentially sick, then I would admit them. I personally wait 48 hours and then fix them. If it's a child where it's reduced easily and they live locally, to your point, Jack, then I would send them home, uh, and have them come in electively. The timing is is addressing the second question, yeah. Yeah, so I mean, I don't think you should send a child home who's been vomiting and until they're feeding. So clearly I would do that. But then I would try and get the thing done. I would send them home if they're local, and I would bring them back within 72 hours, and that's based on data that we published many years ago that showed the reincarceration rate started to go back up at 72 hours. I've 24, 48 hours. OK. Uh, I, I think that, um, a comment and that will be addressed that was also, I never had a chance to mention from the audience of when we were talking about appendicitis is, uh, a lot of what we do, timing of operation, do you do it at night or the next day, really depends on your own institution and how much free available OR time, uh, you have. So I think this also is the same thing at our institution, we happen to have. Uh, open rooms for us every day for all these add-on cases. So it's very easy to add cases on, but it's not always the case. Um, Aaron, you, if you did admit the patient, uh, you would admit then, or you would, OK, and then when you would not do it the following day, but the day after that because of inflammation, is that why you waited and edema cord. OK. Uh, any comments from the Gallery, um, I do them the next day. I don't wait two days. Um, if, if it's a reliable family, I'll send them home to be done, but I have a date for when I'm gonna do the surgery within usually the next 3 days, kind of like what Doctor Langer said. So I try to get them done right away. If it's one that uh reduced on its own, the ER reduced it without much effort, and the family wants to wait longer, I certainly would wait longer. Yeah, I usually do them the next day. Sometimes they don't come back or it's hard to schedule. Same thing, same thing. No. So the only thing I'll say is that for one advantage of laparoscopy, again, I'm gonna keep putting my, uh, is that I don't think there's any, in fact, the edema helps you. Uh, I'm not sure there's any, uh, concern with the edema, so you could do it right away with laparoscopy. So, all right, yeah, I, I've never felt that the edema really was a big factor, although maybe I just don't have a large enough end to be able to really control for that, all that, but. Uh, but yeah, so, uh, and I, I, I don't. I, I would probably just try to do it the next day or if, if the OR couldn't accommodate us, then 2 days maybe, but that would be the longest we'd have to wait at our institution, so. Alright. And then there's still here we go about the contralateral side. I don't know if we beat that horse to death yet, but we can move on. And then, uh, what about the incarcerated ovary, because I remember during my training in resident general surgery residency and, and, uh, um, fellowship that there was a lot more anxiety. It seemed like there was a lot more anxiety about the incarcerated ovary back then. Um, because I guess the study from 20 years ago that suggested that there's a high incidence of torsion and, uh, and ovarian loss, but, uh, I don't know, I get the sense, so I'm kind of curious how, how people, uh, are, are thinking about that. I don't have a poll question for that, but maybe we can go around the room and ask. I mean, do we treat ovary incarcerated ovaries differently, or so I, you know, the teaching was, has always been, you got to do it within, you know, it's not emergent, but it's urgent. You need to do it within a few days or a week. I bet you that's not true at all. I, I don't know, but I, my guess, and I do that, but my guess is if you waited a month, the ovary would still be fine. But I do it within a week. I do it within 3 to 7 days. I do it within 3 days or yeah I do it quickly and they're gonna need their hernia repaired you might as well just do it so I don't really see the the risk benefit is you risk losing the ovary if you wait. I actually wait. I do them electively, and I don't, I mean, it may be the wrong thing to do, but I haven't had a case where I've recognized ovarian loss doing that. And I've got a lot of them where they were out in the office because most of these are outpatients I see and then they're, they're back in when I operate on them, no matter how many days have passed, I think they do kind of come and go, so I don't make a big deal of it. So maybe the way we'll do this for time is that if everyone agrees with what's been said, then, then OK, but raise your hand if you have a different opinion so we can get. All the different opinions. I actually had a different opinion about the contralateral side when they've presented incarcerated, because there is some testicular injury when they're incarcerated, so I always look at the other side or explore it either laparoscopically, make sure they don't have a hernia on that other side, because I've seen a few cases where they have a pretty ischemic testes with small hernias that have been incarcerated for 68, 10 hours. That's a good point. I think my, I mean, I've been more concerned about the testicular atrophy and, and ischemia than with bowel ischemia. It seems like that's. I don't know. My perception is that it's less and less likely in this day and age, but, but that testicular ischemia is harder to control for. But then again, looking in the literature, I think you can look at it both ways again, because one is that if you're operating unnecessarily on a patent prosthesis on the other side, that's never gonna incarcerate anything, maybe you've exposed that testes to, to injury whereas you otherwise wouldn't. And I'm playing devil devil's advocate because I don't know the answer, but, uh, but it's, it's an interesting and tough question, but I, I, I think I just don't change my Approach, I still explore the contralateral side when I, when I have the opportunity. Tim, you, you, I was gonna say the corollary is the, the torsed ovary that's, you know, 5 centimeters in black. We don't take those out anymore. We detorse them and they survive. Get an ultrasound later. So I think that's, it's less urgent than we think. Yeah, yeah, that, that, that could be for sure. And so this was gonna get to the question of contralateral exploration, but I think we've already sort of, like I said, like we talked about, beat, beat that up, uh, a little bit, and we talked a little bit about the technique. There's 11 person in our group, uh, Scott Adzik, who, who uses the needlescopic, uh, technique, and it's actually seems to be quite easy and safe, although most of us just put a, a 70 degree scope through the contra through the. Hernia sac and and feel like we get a good view there although I've also had kids who I thought were negative who came back with a hernia, uh, months later, so it's probably at least with my end about 11% inaccurate. The needle scope is great. I, I would love to ask that how many times it's been broken. Um, that's why we, yeah, I mean they're very fragile, but they're amazing scopes. We need a uh Uh, this, this is just a video of something that we've probably all seen before in terms of the so-called hernia bubbles, but that's OK. We can, we can move on to the next, uh, the next. What, what is the point that you're making here though? Well, just that, you know, it's sometimes hard to tell whether there's a hernia or not, but if you, if you manipulate the, the, the, uh, the portion of the sac that's in the scrotum or the spermatic cord, you can often see air come through and it's visualized as bubbles. That's all it's. And by the way, Joy or Pablo, just chime in if there's anything there, because I'm not going to see you, so just say something if you want to make a comment. You. OK, so we'll, we'll move on from the uh contralateral exploration question. Um, So, OK, this is an 18 year old, so this gets into the other extreme, uh, from the, from the former preemie who's still a neonate, uh, the, the quasi-adult, you know, the 18-year-old male, uh, for example, with an inguinal hernia, and it's to your exam, a typical indirect inguinal hernia, uh, it's easily reducible, maybe some discomfort, but, but certainly no pain or episodes of incarceration. So the question is, do you treat them like a, like a child, uh, like a child's type hernia or like an adult type of hernia? Cause I've had surgery residents come through and they, you know, kind of, uh, give me a hard time because I'm only ligating the sac or I've given away what my, what my, what I, what I generally do. But the question is should we be doing more for these kids? And the question is, do we use a mesh or do we use a, uh, uh, yeah, I definitely changed, updated that question. I apologize about the whole plug-in patch because it's an old fashioned. Um, so I think this is my first, the first version of the, of the slide deck that I sent you, but that's OK. Mark, did you say he, he, he said, do you have a more updated version than this one? Um, well, why don't we go through, I'm just curious. So, so I know I have a strong opinion on this, but I want to hear everyone else first. So Dan, how do you deal with an adolescent? Yeah, I think it's a great question. Honest, my honest answer is, uh, I struggle with these a little bit because I think that, uh, had I trained at a different era, I might approach them more like an adult hernia, but I still treat them like pediatric hernias unless I think I had a 240 pound football player and so he got an adult mesh repairs. I, I do high ligation through a small little incision even if they are a football player. Aaron, what are you gonna do? I will treat him like a recurrence and then I'd maybe do the Yeah, you don't burn that bridge. So, so, um, I, I feel not only strongly that adolescents can get a high ligation, but I think they should be getting it done laparoscopically, um, and the reason for that is you can, uh, clearly evaluate, um, without, so the advantage of laparoscopy is, and you don't have to. Uh, go through all that tissue, which I think is a, a morbid, uh, incision when you potentially because inguininia, inguinidinia is a much more common problem in older patients than we see in little children. It's actually a very high percentage rate of postoperative chronic pain. So as you get older, I think that incision becomes more of a real deal. I like doing them laparoscopically. We've been doing them in any age group laparoscopically, as long as I believe you have to cause scar anteriorly to cause it to heal. We've shown in rabbits that when you do that, it's completely obliterated even without a stitch. Um, but the, the thing you need to look for laparoscopically is, is this truly an indirect inguinal hernia or has the, has it become a muscle problem? Has the hole become massive, like you see in the VA hernia, or is it a small? Indirect patent prosthesis vaginalis in those patients. I do those laparoscopically high ligation. And I have not had a recurrence yet. We're gonna wait about 5 or 6 years and then publish our data. So do you think you can, you can tell it with laparoscopically whether they have an indirect, whether they have a direct, so-called direct inguinal hernia? So the, uh, the, the advantage, yes, the advantage of the laparoscopic approach is that our most common, uh, based on that Mayo Clinic study, if you look at 50-year follow-up, the most common cause of a recurrence after an open inguinal hernia repair in a child is a direct hernia. And that's because we're either messing up the floor when we're going in to do these in the tiny preemies or we're misdiagnosing direct hernias as what we think is a patent processes vaginalis. Laparoscopically, you can see the floor perfectly. You can tell if this is a floor problem, if this is a muscle problem, or if it's a small little indirect inguinal hernia that hasn't stretched out over time. Um, I, we are starting, actually, we already started enrolling patients. We are studying this in adults now. Um, so the, we're doing, uh, ultimately a five-center study. Obviously, not me, but the adult hospitals are doing a randomized, uh, uh, prospective randomized mesh versus just laparoscopic hyal ligation in adults because I think that it works fine if they don't have a huge defect. So I, I, I do, I, I do offer families the choice to, uh, perform a laparoscopic mesh repair, especially for that athletic 16 year old football kid, um, who wants to be able to go back to play, uh, before the season ends, and, um, so I, I offer people the choice of both procedures and a fair number choose that the, the mesh implantation. To be able to go back and play. So can I just say something that that mesh, just so you know, has a 30% incidence of chronic pain that's been validated in multiple studies. OK. Also, it has a significant injury to the vas deferens. Most mesh repairs done by the adult surgeons are in patients who are not planning on having any more kids. They're usually older patients. So you have to realize that mesh is no joke, um, in an adolescent, especially if it's a bilateral inguinal hernia, that you're going to be putting mesh right on their vase. Um, so I, I think it was Aaron that said, I'm willing to accept, even though it hasn't happened, that they would have a recurrence and then get a mesh repair and try to do a high ligation first. Than putting mesh into someone who is ultimately gonna want to have kids, that's happened in my practice. I, I did mesh repairs for a while, and then when the studies came out that it caused infertility, I, I'm back to high ligation. Just, just, just to be clear though, I'm talking about, uh, an extraperitoneal mesh placement, not, not an open should ice mesh repair. Yeah, I have the same concerns about the mesh though, and, and, and maybe it's mostly just founded on, um, anxiety, my anxiety, you know, or, or the late night lawyers commercials that we see all the time about mesh, uh, but so because I expect that, you know, they're gonna need to keep that mesh for 80 or 90 years sometimes and Uh, I'm not sure what it's going to do over time. And so, uh, I'm actually myself partial to an open sort of old fashioned McVeigh or Cooper's ligament type of repair, but I may be a dinosaur for admitting that. But I think if you, if you look, and, and I, you know, I'm probably regionally, it's different, different surgeons, but if you, if this, uh, 17 year old or 18-year-old, this is an eighteen-year-old, an adult, ends up in an adult hernia surgeon's office. They're almost certainly going to get a mesh repair now. They will give me 5 years. They won't be doing it. So, but I just, I think for the audience and for the, at least in this country, I don't, I would be curious to see if in other parts of the world if there's a different perspective on this issue. Uh, so especially where mesh may not be as readily available, did we, Jonah, did we put that poll up? Uh, can we see the poll results of, of how people manage, um, uh, adolescent hernias? We'll get that poll result, and then, um. I'm not sure we can tell by region, but maybe people can chime in by chat. Uh, I know Yama had to go because it was 3 in the morning and uh Marcello is doing an esophageal resia repair, but we do have Gloria Gonzalez on the phone, uh, on the chat, so she can answer us. We're just curious if this is done different by region. So why don't we go ahead to the next question? Results are up there. So it looks like. Um, if mesh is mesh repair ever indicated, uh, and 50% say no, um, almost never, 30% say yes for older adolescents and young adults, 6, 16% say yes for any child with a direct inguinal hernia. Really? So even a newborn with a direct hernia, that's interesting. OK, well, I guess to the question of when you're doing an indirect hernia repair, and this is open, obviously, and, um, you know, that, that the inguinal internal inguinal ring to your, to your eye or, or to your feel seems sort of generous. I mean, we, we, this used to be controversial whether you should put a stitch or not or whether you're gonna stranggulate the cord or whether you should always just assume it's, uh, just a hernia sac, but, uh, um, does anybody ever put extra? Extra suture material, not necessarily a mesh, but in a newborn with a large, yeah, I just tighten up that internal ring with a couple of basini stitches, um, solving stitches, because I think, I think what sometimes happens is you start with an indirect hernia in a small baby and it turns into a direct hernia because the floor just gets blown out by the stretching, especially those very large ones. I, I don't routinely, but I have a few times had to do that. So it's a sleep at night stitch, yeah. Alright, so, um, so I think this one is just a straightforward six year old boy presents with a, with a fairly classic garden variety inguinal hernia. It's reducible, uh, and the testes are descended, um, and so this gets to the question about laparoscopy, and this is really maybe to, to. To educate me because I kind of thought, well, laparoscopy, that's, that's so new, I'm not sure who's doing it and who's not doing it, but, um, so, so, but I do get this question now more and more parents are asking, do you do it laparoscopically? because they know that you can do these laparoscopically now. So, uh, I don't know if this is, if we can do this as a poll question about who does them laparoscopically, who doesn't, and, uh, some who are intrigued by by the concept but haven't really been, uh, courageous enough to give it a try. Jonah, can you put a poll up? OK, great. And, uh, can I start off by, so I think we have to be careful of the term laparoscopic inguinal hernia repair because there's about 50 different versions, um, and Felix Shear was one of the originators who does a Z stitch in and out and his recurrence rate was about 6% and and then Craig Albanese and Mike Harrison and Sanjeev Dutta and Stanford do what's called the seal technique where they put one big stitch in. They report 1.2% recurrence rate, but other people that have used that technique report a little bit of a higher recurrence, about 3 or 4%. CK Young, um, who does an extraperitoneal percutaneous, uh, stitch, um, dissecting between the cord, um, circumferentially, uh, and not skipping out, um, has, has not published his data yet. But has less than 1% recurrence. Um, and I can tell you, um, we have not published ours, but anecdotally I've probably done several 100 I know I've only repaired one recurrence. I probably have two or three more out there. I don't know. So my guess is that I'm at around 2% recurrence rate. Which is probably at least equivalent to the open repair. So again, my point is that the recurrences for the open repairs will be maybe later in life and then maybe direct. Um, ours would be failure of the stitch for whatever reason. Since I've added cautery, um, I have not had a recurrence. So, um, I just want to make sure we understand that laparoscopic hernias is a tough term to use. How about with the laser? So it looks like the poll, well, we could, uh, so that was the question is the technique because the poll is, uh, sorry, 37% would not do it laparoscopically, uh, 25% would do it laparoscopically, and 30% said there might be some value in it, but I haven't tried it. So 30%, uh, would consider it. 37% definitely not. Well, I think, I mean, from, if I could speak for everyone else who's in that third category because that's where I am, um, I think we're waiting to hear, you know, what is the best technique. I, I don't, I'm not sure any of us really know what the, what an acceptable recurrence rate is because, you know, I think. Uh, that my recurrence rate for open is much less than that. I think it's much less than 1%. I, I, I, my sense is that it's more like 1 in 200, but maybe, maybe, maybe not, maybe there are other, maybe they show up to my partner's clinics, I don't know, but, um, so I don't know, is 1% or 2% too high? I mean, what, what do people think? What's an acceptable recurrence rate? If you can do it laparoscopically, and I, you know, I, I'm definitely of the philosophy that if it can be done laparoscopically or minimally invasive, even if the results are equivalent, that it should be done minimally invasively. I mean, unless cost is an issue, which we, we will ignore for now, I guess, um, uh, but the, but the question is, you know, what's an acceptable rate? What should we be looking for? Doctor Ein, you know, published obviously a series with 5, 5000 cases, and my recollection is he had about, uh, a 1% recurrence rate. And, and our institution, John Atkins, um, was about ready to publish his series, about 4000 something cases, uh, and about to mail it in when Doctor Ein's paper was published, and he had about a 1% rate of recurrence in his series. So I think that's probably the right rate, and I agree with what you just said which I think is key is we have to wait to see how it all pans out to see which specific laparoscopic technique. I mean, I can tell you 20 right now, there's people in South America that do a laparoscopic excision of the sac and that's it. Uh, there, there's people that. Uh, you know, that, that do laparoscopic purse strings. I mean, there's a million versions and we have to see with a good series what what the true rate is. It's not only about the recurrence rate though. It's about what are the potential advantages of the laparoscopy. In our, in our system, cost is an issue, and there's no question it's more expensive to do it laparoscopically just because of the equipment and because you need an extra nurse. And uh, so I would have to, just from a cost point of view. I would have to have a good reason. To do it laparoscopically, um, and the most compelling argument is, is, I think, still unproven, and that is that you're not handling the vas and that you may have a lower incidence of, uh, of infertility. Um, but that is going to be a very hard one to prove without really long term. So the, the, the data on that, um, Jack, is that there's about 3 or 4 studies that have looked at the sperm count, sperm quality. Um, of, of patients that have had inguinal hernia repairs. I have the data in my computer that I'll get in a minute. Um, and they've definitely shown decreased sperm quality in patients that have had bilateral inguinal hernia repairs. However, the infertility rate did not appear to be different. There was one study that showed yes, and several others that have not shown the difference. So, um, It's questionable, right, but that also doesn't look at the, that's you're making the assumption that the laparoscopic approach is going to have a lower incidence of that injury, but that's not, I've watched videos and I've wondered, you know, whether they're really, whether they're really preserving the vas or not at the risk of being thrown out of the room in the back corner, um, you know, the other question I would have for Todd and for those who advocate the laparoscopic approach, there's a point, and as someone who Uses the umbilicus for a lot of other procedures. There's something that bothers me about creating a potential hernia site in the umbilicus to bring in my camera when I can make this and to bring it into an area that's visible to some degree. And granted, it's a small port and it tends to turn out fine, but. Certainly from the single site surgery using the umbilicus, the satisfaction of patients with what we call an adequate closure afterwards is not always the same. And depending on your technique, some people, especially for girls, will put two other incisions, uh, kind of like a lad's procedure in the midclavicular line to, to do dissection and to deliver. So now you got 3 incisions that are above the underwear line. So I'm not sure even from a cosmetic point of view, it's, so anyone that argues cosmesis for laparoscopy, it's, it's not a valid argument because I think you have 2 incisions below the underwear line. Um, I, the answer to the umbilicus is you just pulled everyone here about appendectomies and not a single person in this room has ever had an an umbilical hernia after, uh, doing an umbilical incision. So, um, I use a 3 millimeter port. My guess is it's negligible, if anything, for a hernia recurrent hernia rate, so. I have one partner who is worried about an increase in small bowel obstruction because you're creating an intraperitoneal's valid, uh, point of adhesion, but I mean, uh, and that's another thing that we won't know probably for many years from now. This is just a series of pictures. This is uh CK Young's technique with the, with the hook. Um, that, that I believe he developed and this is Alan Flake actually who's currently the only one in our group who, who does it this way, um, who does it laparoscopic using a laparoscopic approach. And, um, you know, certainly look looks very comforting to see that cinching of the, of the sac, although I'm curious about your, Todd, you, you, when, what made you Start to cauterize the, the edges to try to get better. Is it just the, the fact that it's two slippery surfaces that you're worried about surfaces don't come together. And what we did in the rabbits is we just did the stitch and waited two months and cut the stitch out, and they all opened. So I don't like the stitch relying on for life. So I like to, we cauterize, then cut the stitch out, and they all closed. So they all stayed closed. I think one thing that's got to be said is that it's a great The, the bar is very high for the open operation. It has a very low recurrence rate. The cosmesis, as Todd just said, is quite good, and, uh, it's been around a long time and it's going to be a hard operation to beat. Yeah. And prove that the one's better than the other. So then the other question I guess it gets to is the learning curve because some people say it's up to maybe 30 or 40 before your recurrence rate is low enough to be acceptable. So, uh, for such a common operation, do we want to expose that many kids in the world? I mean, should we all just kind of start doing it, you think, or what's your opinion? Should we all start doing laparoscopy. Is that the only way we're going to get better, or we should we wait for pioneers like yourself to kind of show us, show us the way? I think that's a tough question. I've never actually been. I mean, I guess in a naive way, I always say, I always encourage everyone to be doing it laparoscopically because I can tell you, um, is, it's just, especially in certain patients like the little preemies, it's such an easy operation and there's so little risk, um, that I think that it's a nice way to start in a patient that might be a recurrence, uh, it could be anyone that might give you any heartache at all, the laparoscopic procedure is so easy, and we know that the recurrence rate, if you do it certain ways, is about the same. I wouldn't, and then maybe if you could get comfortable over time, start doing it, but I, I, I don't, I think that doing it open is just fine and I don't push people, I don't feel very strongly, I just think that's what I do. Well, I think it might be the preemies that pushed me actually into that realm just because that's one of the operations that I dare I say hate the most. I mean, it's, I find it very, still very difficult and anxiety provoking, and, and actually when I talked about my recurrence rate being so low, I was mentally excluding the, the, the two or three that I specifically recall who were preemies who had recurrences within the first few days. So I guess if you include those, it's more like 1%. All right, so let's see if, uh, And then we talked about this a little bit. There there's really no consensus, I think, as to what the, which is the best technique. And then what about the hydrocele? You know, um, I, I know a lot of us, when we do, even when we do open, uh, operations, we, some of us sort of just leave the distal sac open, uh, some, most of us wouldn't try to excise it, uh, but, you know, maybe it was because I was early on in my, in my career when I started getting complaints from families to say the hernia is back, and I would have to spend a lot of time trying to explain to them. That's not the hernia, that, that's, I know that's what you saw preoperatively, but that's the post-operative hydrocele that will go away. And, and so maybe for to try to combat that, having that conversation, I am a little more aggressive about opening the the and partially excising the distal sac, but with obviously with laparoscopic, you're, you're just leaving it. Is that, is that a concern or am I wrong to be concerned about that? I, I, OK, so, um, I don't think it's, uh, concern just based on numbers that, um, that the incidence of that is very low and that people that have had it, I've had one, it was actually when I did the asymptomatic side and a girl, and she got a canal of nook hydrocele, um, but I waited a month and it was gone. So, um, so it's probably just me. I think if you've actually occluded the sac, then it should resolve. That's right. Uh, I think that also putting that stitch causes ischemia of the distal sac, and it will, uh, absorb over time. Can I ask you a question from the audience? Uh, there was a question about, and you might be addressing this later, if you're going to do, it says, uh, from Tarun Kumar says, um, a kid with a BMI of greater than 30 during a lap Api, you see without perforation, you see a hernia. Do you do it to avoid doing, do you just, um, do it at that time to laparoscopically, I my guess is what he's asking, to avoid surgery in an obese child, um. Well, I personally have done it in incidental hernia repairs in a girl I would because I, I think that that's a more straightforward approach. I feel like I've done that enough times laparoscopically that I can deal with that. In a boy, I think I would probably just call to the family and let them know I'm recommending that we make a separate incision and fix the, the hernia the traditional way. That's just my, my approach. Any comments from the panelists about incidental, uh, yeah, sorry. Yeah, I don't think you should be doing. Incidental hernia repair if you're due, if your purpose is to be doing another operation because you don't know if that, uh, that hernia sac, well, it's, the hernia sac's not symptomatic at the time, and there's no way to know if this could be symptomatic in the future. OK. So, I would identify it and let the family know that it's there. If there are ever symptoms, they'd come back and see you. But that, that is inconsistent with your practice of exploring the other side, of looking at the other side, because I think that there's a difference between if they have a hernia disease on one side, uh, and you've talked to them about giving them the option of fixing the other side is different than doing a, a laparoscopic appendectomy and finding a patent processes. Uh, they're two different disease processes. Yeah. I, I, I've seen that before and I, I just don't like doing a clean case during an infected case. I also worry about the fact that you, you take a potentially infected site in the scrotum because it communicates to the peritoneal cavity and then you close it off. Close it off. And so that's why you created a scrotal abscess by fixing the hernia. It's like doing a laparoscopic labs and a missing at the same time, right? I think a more common, you know, like a pyloric or something that's not infected. I remember at the at the course in Chicago, uh, someone, oh, Cathy Barson said, Who here would fix this? And she showed a patent prosthesis, and I was so excited. I raised my hand and I realized that no one else, so I put my hand back down. So, um, you know, I originally was thinking, yeah, I'll fix them, but I think that I've been educated through forms like this that I actually don't do that now. I think their point was if it's a potential easy fix right now versus a much more challenging operation in the future. Um, you do it, but I'm not sure that everyone here would do. I, I've had a paradigm shift because I would, I would fix them later, and, and now I'm really careful to make sure it's a hernia, not just a small p process, because I've explored a couple three months later and found just a little nubbin of something, and I'm like, did I, did I really even see it? I wasn't sure that I wasn't there for the wrong reason. So I really make sure it has a hernia, and then I can feel it when they come back and follow up or that they have something. Yeah, and I think the frank peritoneal contamination is, is an issue too. I mean, if it's a perforated appendicitis, you probably don't want to. Uh, do that, but, um, but I generally fix them just because that conversation with the family is kind of tough, I think. I mean, at least in Philadelphia it is about, oh, what do you mean you, why didn't you fix it? now we gotta come back and now we have to take a day off from work and things like that. So, I was gonna ask the panelists, and a girl, do you close the internal ring a little pissini over it, or is it enough to just high ligate it? High ligation. Yeah, most of the time I don't, but if it's, if it, it's, it's a, it's a freebie, I think, uh, I mean, obviously you have to be careful. I don't want you're gonna injure the nerve. That, that, that's my concern. I, I was curious whether there is any, I, I don't know the data, but is there any data to, I was taught to do it, but I, but lately I've not been doing it because I don't know why it would be any different. I do it. You do close it routinely? I put one stitch if I do it if it's easy. Yeah. Yeah, I'd do it if I have to, if you've got a sliding component with the tube. Oh, sure, yeah. Or the ovary and you have to transfix the sac higher, then I'd do it for that, in that scenario. So Pete, let's just do rapid fire now. Just go through, get answers, no discussion, and we'll just go on to the next thing. Well then, the next question really is just a child, a 3 year old with a hernia, but has a retractile testes on the same side, not an undescended testes. I don't know if we have to get into that, but I guess part of the question. Is, uh, especially since it seems like at least at our institution, our general surgeons are doing fewer and fewer, uh, orchidopexies. If you, uh, had a retractile testis, do you, uh, fix the hernia and leave, put the testes down in the scrotum and hope for the best, or do you do an orchidopexy, or do you call your urology, uh, colleagues? If it were, if the testicle came up into the inguinal incision, I would do an orchi fix. Well, if it's, if it's really retractile, then uh then I would just fix the hernia. Yeah, I'd agree. I must have, first of all, when they retract out, usually when they get paralyzed when they're asleep, it's, that's true. Um, I think the free floating test is that you see a lot of times in the preemies, you got to do an orchiopex. Well, that's the, that was the next part of the next question is, so then a test is that you're not really confident about the gubernaculum. It seems really way, way too mobile, and I guess you have to put it, I, I don't know, I think I kind of feel obligated to do it because I worry about a, uh, I don't want to come back to have to do it after or send it to somebody else when there's all that scar, but. And there are reports of postoperative cryptorchism after hernia repairs a few percent. Alright, and we don't, I probably don't have time really for uh the umbilical hernias, but again, this is maybe mostly for my, for my own, uh, education. Um, so what, what age are we supposed to repair umbilical hernias? I mean, how long do you give them to, to close on their own? Um, and, and I thought this was settled, but I, I, it seems like it's controversial, but, uh, and there's some discrepancy even among, amongst our group at, at CHOPS. So what age do you, do you recommend elective repair, unless it's tiny, I, I, I, you know, that's a different story, but. Uh, well, um, I'll do it at 3 to 5 years of age. I beat them at 3. I tell them, do you want to, you know, you can wait a couple more years. If they don't want to, I'm willing to do it at 3. Um, it's 3 to 5 years. I'll put them off until they. And by the way, size does not matter for me. I don't do it earlier if they're bigger because there's no data to show that it makes a difference. Yeah, I think the same preschool unless it has been getting smaller because they can go up to 8 or 10 years of age. So if it's getting smaller, I keep watching. 3 to 5. OK, yeah, 3, and I let the families decide. OK, if there's anyone who has a different opinion, otherwise. And then what about with redundant skin? Some people say you should just, uh, leave it, uh, no matter how proboscoid it is, or should you do an umbilicalplasty at the time? Uh, I, it's a debate in our group. I do umbilical plasties if they're really big. If they're not really big, I don't like. Yeah, I do umbilical palsy. However, you don't? I have not, but I will. Well, we could spend another 20 minutes just talking about the different techniques that are available for umbilical plexus. I think some are, some are OK. And of course each one of us will say the way we do it is, is the best, but I will tell you that the way I do it is not the best technique is the is the best approach. Mine is the worst except for all the others, so. Alright. And then can I just say I leave it alone most of the time. I hardly, hardly ever do it. Yeah, it has to be fairly redundant. Maybe that's because I'm still early in my career and complaints. I haven't had the complaints from the family. I think it doesn't look what I counsel is that it may not look it won't look perfect when I finish, but that in general terms, maybe because I trained under Dr. Keene and he didn't do that when I got to see his later. They look great. Yeah, well, I think that. Critical actually, uh, because I think a lot of what we do, and this is, you know, is managing expectations. I mean, I think in some families handle that better, but if you explain that, you know, as they grow, they'll need that extra skin and, and as teenagers when you want it to look good is when, when they're gonna look good, because even my umbilical plasties, I still need some extra. I, I try not, in fact, if it looks perfect, I worry that they're not gonna like it when they're 19, but then they go for the umbilical ring. Um, the next was about, about femoral hernia and then about, uh, Plocele, but I think we can skip ahead to tomorrow. All right, real quick though, real quick though, uh, Plocele, uh, epigastric hernias, who fixes, does everyone fix these if they're asymptomatic? Because I don't. Do you? I, I do not unless the family. I will bow to family pressure occasionally. OK. I only do it if it's symptomatic. Symptomatic is rare. Yeah, good. I fix them all if they come to my office. You fix them all. Fix them all. It's like a barber. You got a mortgage. You get a haircut whether you want or not. I mean it's interesting. One of the reasons. I fix them is I've seen a couple that were, became symptomatic as a teenager. Yeah. And the patient gained a whole lot of weight and then trying to find. Oh. Find it, uh, on a, a teenager who's a little bit overweight, it's all, you can't feel it. So, you don't know where to make finding is very difficult, yeah. So, so, I fix them when they're skinny and it's quite easy. I think you can't find it, why do you need to fix it? Well, if they become symptomatic, you know, they had an epigastric hernia that no one fixed, and then at age 15 they came back and having chronic pain in that area and then it was, yeah, well, my one pearl is to mark it before they go to sleep because once they go to sleep, you can't find it. Also, it's probably an error to operate when they're too young, when they have the, that's a disruptive fascia. They'll get more of them later. So, so we are going to move on to the next one. Pete. That was great, and I'm sorry we couldn't get to everything, but that's all right. Yeah, hernias is just no controversy. That's right. It's all settled. Uh, moving from one type of hernia to another, uh, we're now going to move to Jack Langer, who's going to go over abdominal wall defects.
