E95 Masterclass with Michael Rosen on Abdominal Wall Reconstruction
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Michael Rosen 00:00
There's a thunder and lightning storm and a tree fell on the roof and the water is pouring in. If you call the roofer, they're not going to go out there and rebuild the roof in the thunder and lightning storm. They're going to put a tarp and tell you to call back when it's a nice sunny day. And so, when it's a nice sunny day, you're going to go out there and make a beautiful roof.
Chad Ball 00:32
Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We've had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been broad in range, whether clinical, social or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.
Ameer Farooq 01:15
A big welcome to all the surgical roofers joining us on the show! We had the inimitable Dr. Michael Rosen on this episode. Dr. Rosen is a world-renowned expert in abdominal wall reconstruction at the Cleveland Clinic, and on this episode, he gave us a masterclass on all things hernia. We did want to do a quick overview of some of the terms used in the episode for any medical students or residents listening to the show. Of course, you can always go to Dr. Rosen’s beautifully illustrated Atlas of Abdominal Wall Reconstruction for a more in-depth explanation of all the topics we talk about today on the show. Ok, so quickly, the layers of the abdominal wall are the skin, subcutaneous tissue, scarpa fasia, followed by the external oblique, internal oblique, transversus abdominis muscle, and transversalis fascia. The linea semilunaris is a bilateral vertical curved line in the anterior abdominal wall where the layers of the rectus sheath fuse lateral to the rectus abdominis muscle and medial to the oblique muscles. The linea alba is a single midline fibrous line in the anterior abdominal wall formed by the median fusion of the layers of the rectus sheath medial to the bilateral rectus abdominis muscles. Basically, it’s right in the middle, where we try to place our incision for a midline laparotomy. Finally, the arcuate line is a horizontal line that demarcates the lower limit of the posterior layer of the rectus sheath and is usually 1/3 the distance from the umbilicus to the pubis. All of these various layers are extremely important in understanding the various surgical approaches to fixing hernias. Now, again very quickly, we ask Dr. Rosen about a bunch of different techniques. A rectrorectus repair involves creating a space below the rectus abdominus muscle in the preperitoneal space. A TAR is the transversus abdominus release and is an extension of the rectrorectus repair, where the posterior rectus sheath is incised, the rectrorectus plane developed, and then the transversus abdominus muscle is released medial to the linea semilunaris. This preserves the neurovascular bundles and allows the surgeon to reconstruct a functional midline. There are a couple of minimally invasive techniques we also discuss in this episode. A TEP or totally extra peritoneal inguinal hernia repair is exactly that, where access is gained into the preperitoneal space and the space is blown up with balloons, and the hernia is fixed in an extra peritoneal fashion. An e-TEP is an extended or enhanced extra peritoneal hernia repair, where a large working space is created than a typical TEP. A TAP is a transabdominal preperitoneal repair, where access is gained to the abdomen and the groin hernia is fixed via the abdomen. Finally, an IPOM is an intra peritoneal onlay mesh where a mesh is placed from the inside over the hernia opening, typically in a minimally invasive fashion. Hopefully that quick review refreshes those terms in your head, and we can go on roofing, in rain or shine, with Dr. Mike Rosen.
Chad Ball 05:09
Tell us a bit about where you grew up and what your training pathway was like.
Michael Rosen 05:12
So probably to many people's surprise, I'm actually a southern boy by heart. I grew up in Atlanta, Georgia. I actually went to high school, public school in Atlanta. And then I went on to college at Vanderbilt, in Nashville, Tennessee. And when I was there, I actually was really interested in biology, and was actually going to be a biology professor. And that kind of took me my year after before I went to medical school. I actually was a field researcher, studying the migration patterns of black widow spiders and scorpions, all throughout the deserts of the Southwest, Baja, Mexico. And I even spent a couple months in southern Africa. And when I came back, I was actually a ski bum in Vail, Colorado for just about a year. And then went to medical school at the University of Southern California. And then did my residency at Mass General in Boston. And I spent two years at Cleveland Clinic, doing minimally invasive research with Jeff Ponsky, that kind of got me where I am today. And then when I came back, I finished my fellowship with Ty Heteford in Charlotte, North Carolina, doing a double wall reconstruction, and minimally invasive surgery, and then I've been a Cleveland ever since, going on about 18 years, the first decade, I was at UH. And the last eight years I've been at the Cleveland Clinic.
Ameer Farooq 06:46
It's always amazing to hear you tell your story. And other stories about like, you know how you did this cross country bike trip in the last year of medical school, and it's always impressive to me kind of how varied your life has been. And it strikes me, like a lot of the guests that we've had on have similar kind of very varied life experiences that just explore lots of arenas in and outside of surgeries. I always find that fascinating.
Michael Rosen 07:15
Yeah, I think, you know, one of the things I like most about surgery and that bike trip and all those types of things is kind of living your life at the extreme and getting the most out of it and challenging yourself. So I certainly my extracurricular non-surgical activities are all about, you know, kind of trying to push the limits and see what I can do. As I'm getting older it's getting harder, both surgically and non-surgically, but I certainly still inspire.
Ameer Farooq 07:42
You mentioned that you trained with Jeff Ponsky and I've heard you talk about the really good advice that he gave you sort of as a young staff starting out, where he actually kind of got you interested in abdominal wall reconstruction. Like, you know, I think now, abdominal reconstruction really has a place in the surgical kind of fields and there’s a certain, I don't know if the honor is the right word, or there's certainly some recognitions that are given to people who do some big abdominal wall reconstructions, like yourself, but I don't think at the time that you got interested in it. People really felt the same way. Can you talk to us a little bit about how you got interested in hernias and abdominal wall reconstruction, and particularly kind of what Jeff Ponsky sort of told you when you got started?
Michael Rosen 08:27
Sure, sure. So, Dr. Ponsky is my mentor. And, you know, he's certainly guided much of my career. And I think that it's kind of a fascinating story, because I mean, you know, to put it bluntly, as you kind of suggested, you know, 18 years ago, fixing hernias was not cool. It was basically, you know, everybody felt like they could do it, it certainly wasn't considered a specialty in any way. And it was somewhat novel to think about doing that. And, you know, to be completely honest, it was something that really wasn't even on my radar when I started. And I think that's probably for most young folks, one of the hardest things is to let yourself be mentored. And so, you know, when I started at UH, Jeff Ponsky kind of pulled me aside one day, truthfully, I think it's because he just wanted to give me a terrible patient to fix. But he kind of pulled me aside and said, well, Mike, you know, I'm going to teach you how to make an academic career. And it's still the advice that I give to all my young partners today. You have to pick something in surgery, that we don't do very well, that nobody wants to do, and you have to try and make it better. And I think that's hard for a lot of people because especially when you finish fellowships, you want to do the fancy, cool, sexy stuff that you just got trained to do. And a lot of times, you know, we've already done 1000s of those cases. There's not a whole lot that you can add. But you know, he suggested that I do hernias, and I really, you know, when I started it, I thought this would just be some lap inguinals and lap ventrals. But as I really got more and more into it, I realized that there was just nothing out there about fixing complicated problems. And it's just, you know, I think most of these people just turned away. And so, as I look back on my career, although I was somewhat resistant to getting going on it, it's truly amazing how far this has come. I think, like everything. You know, my final part to that - the other story I don't always tell about Jeff Ponsky now that I'm kind of on the other end of my career, is he also said that the best way to kind of sustain your academic career is start telling people to do things for the first 15 years of your career, and really push it. In the beginning, everyone will be like, that guy's crazy. He doesn't know what he's talking about, that won't work. And after about 15 years of saying it, teaching it and writing about it, people will start to change, and they'll all start to do it. And what that really gives you is the last 15 years of your career, which I'm kind of at now, where you can say, hey, I was wrong. I was wrong, don't do that. Don't do that. That's not what you should do so. So I think it this is kind of coming full circle, it was really great advice. And I tell it to, you know, one of my partners is actually rapidly becoming one of the best chronic growing pain surgeons in the country, you know, he does six to eight a week, and it's truly something that nobody wanted to do. But now it's really taken off. And there's a lot of interest in it. So again, that was kind of my story, it worked out great for me, it's not always hard to take that advice. But it really is important to do it.
Chad Ball 11:36
Now one of the things I think that I find most marvelous about how you communicate is your ability to do exactly that: to communicate really complex concepts and techniques in a very simple, you know, increasingly bite size method. And so, we certainly appreciate you for that. Before we get into the sort of masterclass maybe with you and some of the technical endeavors and approaches, I was wondering if you could start us off by just sort of communicating how you view mesh, in general, and in particular, if you would touch on not only traditional synthetic meshes, but certainly biologics and how our belief, our science and our understanding of them has changed over time. And maybe even your thoughts on some of the coated meshes that certainly industry pushes so hard.
Michael Rosen 12:28
Sure. One of the things about any hernia operation that you always have to think about is there's going to be a surgeon, there's going to be a patient, there's going to be a mesh, usually, and there's going to be a technique. And I think all of those things are important. And all of those things kind of weigh into the results. And I think one thing about hernia surgery is probably technical things. And the things that you can do as a surgeon to really optimize surgery might be almost the most important thing because I always say, you know, there's no chemotherapy, there's no radiation to clean up a bad hernia operation, you got to fix it. So, I think we'll get to some of that stuff in the future. But I think the one thing about mesh, what I tell everybody about mesh is that, you know, if you do a good operation, you respect planes, you understand anatomy, and you're meticulous in surgery, probably any mesh you use is probably going to be okay. If you don't do a good operation, you don't respect planes, you don't appropriately place the prosthetic. Probably any mesh you use is not going to be successful, you know. There's three big categories: there's synthetic mesh, there's biologic mesh, newer to the market now is the absorbable, synthetic meshes. Then it's kind of different variations between them. You know, I think the thing about mesh is that there's a lot of marketing forces around the meshes that we choose. And in those things, unfortunately, when they're not balanced out with science and good data, they weigh heavily on our decisions. And so, you know, I think the biologic mesh has been around for years. They come from different sources, they're processed different ways. We don't really know to a large degree how all those different processing things work in clinical situations because there's been little to no, head to head comparisons and randomised trials for a lot of reasons. But I think that, you know, probably the one advantage of a biologic mesh, is that if you were to get a bad infection, the majority of times they dissolve and you won't have a mesh infection. Long term durability, you know, probably not clear right now. But you probably do give up a little bit for that ability for it to dissolve. And then the absorbable synthetics are really kind of taking off. And again, they kind of promote the ability to say that they go away over time, but they provide structural stability and scar tissue. But again, you know, not a lot of head to head data, a lot of the data that we have are in clean cases so I think all of this stuff really should be looked at cautiously by the surgeon. And you know, if I had to editorialize for a second on it, I think probably the thing that concerns me the most, is the rapid uptick in some of the absorbable synthetics without any data. And what that kind of makes me feel like is surgeons think that mesh is going to give them better outcomes. Not necessarily that, you know, learning how to do the operation better, better technique, that's probably more to do with it than the mesh that you choose. And then the coated meshes, you know, of intraperitoneal placement, which, again, is kind of becoming taboo now, but I actually think intraperitoneal mesh for small hernias is perfectly fine. They are a little bit more expensive than the, you know, uncoated meshes. But I think in the right patient, it's a perfectly fine approach, particularly for laparoscopic ipalms. I think for the smaller hernias, that makes a lot of sense.
Ameer Farooq 16:05
It's so important that we actually know what mesh we're using and why are using it. And I really like the way you broke that down into the surgeon, the patient, the technique, and the prosthesis that you're going to use. I think that's a really, really good, as usual, good way of framing it from you. I wanted to walk you through a scenario. And actually, this was a scenario of a patient that I saw in Dr. Ball's clinic. And this was like, you know, the one time in my residency that a patient actually got so mad that they actually walked out and left the clinic and Dr. Ball had to call and calm them down. But we saw this 50-year-old guy who came in with a previous trauma laparotomy, who had a previously failed attempted incisional hernia and now had this big incisional hernia. You know, and he had had this previous mesh repairs. His BMI was around 40, he smoked. So, you know, when I told him look, man, you need to lose some weight, you need to stop smoking before we would consider doing anything to you. He just got so upset, and understandably so because he'd been told that many times. And you know, just telling someone that doesn't really often work. Can you talk to us about how you would approach that patient in clinic? How would you approach that conversation? And what are some of the things that you're looking for when you meet a patient in terms of history and physical exam?
Michael Rosen 17:25
Sure, so you know, these are very difficult discussions, as you've learned. And the reality about hernia disease is that a lot of it is with people that have a lot of chronic medical conditions that are very, very difficult to take care of. Like obesity, like smoking, like diabetes. And, you know, I think the general theme, I'll kind of give you the specifics of what I do, because it's actually quite scripted are that you need an engaged teammate in this operation. So, my first recommendation is when you sit down and you talk with the patient like that is what I like to do is I like to start out with hope. And so I will typically start out with this patient you describe and say, "hey, listen, you're in the right place, we're going to be able to fix you. And that is my promise to you. That you have a problem that we have a solution for. And this is what we do. So, you're in the right place, and we're going to take care of it." So, I start off with hope. And then what I try to do is establish that there is a team here, and it's going to require me and it's going to require the patient to engage in that. So, the kind of the way that I tend to do that is I'll typically say, well, who sent you to see me? They'll say oh it's Dr. Smith, and I'm like, well, what did Dr. Smith tell you about me? Oh, he said, you're the best. you're the greatest guy. So, the first thing I like to do is temper that discussion. Because what that does, is it puts everything on you as the surgeon, and nothing on the patient. So I will start with: "Listen. There is no magic here in Cleveland, I'm sorry to break it to you. But if there's any magic, it's actually this conversation that we're about to have." And so, I go through... typically this is about obesity and smoking. And I say look, you know, these are the reasons why we think it's a problem. And particularly for a obesity, I say look, you know, no matter how great we all think we are as surgeons, there's no surgeon that could beat physics. And if I put this mesh on you, and you're this overweight, it's eventually just going to tear away. So, you know, we got to come up with a way for you to be successful, and we have many things for you. Medical weight loss, try it on your own, surgical weight loss. We're here to support you. And I actually asked them to set a goal, and I make them set that goal and for whatever reason 99% of people think over three months, they can lose 30 pounds. That's typically what I get. So, what I tell them as I write it down and actually talk to patients about this afterwards, this is the most important part of this talk. Is that I tell them what I'm going to do when they come back, and I tell them, we agreed upon 30 pounds. So, when I see you back in three months, if you really tried hard for the first two or three weeks, but then you started to cheat and started to get lazy. And let's say you lost 17 to those 30 pounds, I asked them to give them a grade from A through F pluses and minuses just like grade school. And they'll usually kind of laugh and it's okay, well, I give myself a C minus for that. And I'm like, okay, fair enough. And we have a little thing that you write on the consents, and I'll put that out in front of them. And I said, hey, listen, when I see you back at three months, if you put a C minus effort up like you said you just did, and you're okay with that, I'm going to let you have surgery. And we're going to sign this permission slip, but on the little side of it, I'm going to write that I'm going to give you a C minus operation. So, are you okay with that? Of course, everybody's like, no, you can't do that. And so I say, of course, I wouldn't give you a C minus operation, you're here for an A. So, if I have to be an A for you, why don't you have to be an A for yourself. And then my final part of this discussion when they leave is I tell them, "listen, on the day of surgery, this operation can take me seven hours. And let's say I got in a fight with my wife before I left, I'm hungry after like 3, I gotta get to my kids baseball game, I can't stand the nurses that I'm working with, and I come out and I have to tell your family all these excuses about why I did half the operation, every one of them would say that's unacceptable, get back to work. So we all have to be on the same team. I have to be an A, you have to be an A. And that's it. So the general theme of that is hope, establish a team, set a reasonable goal, and then hold the patient to that standard. So that's kind of my approach to those. It doesn't always work. Once or twice a year, I have people who storm out. But the majority of people leave happy because they feel like you had an honest conversation, and you care about them.
Ameer Farooq 21:54
It's interesting, there's actually this whole body of behavioral economics research that backs up exactly what you do, which is, you know, essentially getting them to commit, right? And you use this commitment device of this A, B, or C. So, I always love that when you came down and talked to us chiefs in Calgary, and told that technique, I've always loved that. And I think it's so valuable. Specifically, when you're seeing patients in clinic, what are the things that you're evaluating them for, let's say in the exam room, when you're chatting with them, when you're examining them, and then on imaging, is there anything in specific that you are really looking at when you're trying to plan what operation they should get, or if they should get an operation at all?
Michael Rosen 22:41
Sure, so one of the things...and again, let's start with the big cases of the complex situations where you know it's going to be a large operation, with a lot of physiologic strain. Typically, what I like to do, typically the residents will go in, they'll take kind of medical history of whatnot. And they're looking for, you know, particularly contraindications to surgery, you know, like, potentially at home oxygen, if they have, you know, uncontrolled portal hypertension, and smoking, diabetes, and obesity are kind of high on our list of things to try and optimize. But one of the things that I like to do, for most people, when contemplating that just to break it down to just a simplistic thought, is I'll often just ask the patient when I come in the room. I'll just say, you know, tell me what you're doing a typical day. And if I have a patient who doesn't get off the sofa, is not active at all. Then my follow up question is, well are you not active because of your hernia? Are you not active because of some other comorbid condition? If it's because of their hernia, I will often push forward with surgery. But if it's something else, then my answer is it's not worth a life-threatening operation. So, you know, not change your quality of life. Because one of the things about ab wall reconstruction that I actually love about it, is it's a quality-of-life operation for the large part. And again, as we learn how to measure that and really study that, I think it's a very rewarding thing, but you've got to make sure that you're, you know, not taking somebody who you're not going to improve upon that. So that's kind of my general themes about it. I think the other you know, my kind of bread and butter of every ab wall reconstruction is every surgeon that is faced with a hernia problem needs to think about how they're going to fix that based on the three layers is kind of what I like to say. This is how I explain it to the patients. First is the GI aspect of, you know, the severity of the adhesions, or you have to resect bowel and everything that goes along with that. Second is the muscular facial reconstruction. How big is the hole? Are they a minimally invasive candidate and they need to be done open and what layer can I potentially put the mesh in. And then the final piece that honestly, I think general surgeons sometimes struggle with the most, because they don't understand all the approaches to trying to improve upon that is the skin and soft tissue. And I actually think that a lot of mesh infections, and you know, quote unquote, hernia failures have actually nothing to do with the mesh, but they have to do with the breakdown in the skin and soft tissue coverage of your repair. So I think a very careful assessment of that, where the scars are, what the blood supply is going to be after you do whatever operation you're going to do. Do you need tissue expansion? Do you need to undermine the skin in order to get the skin closed? Do you need potentially a free or rotational flap, are all things on the kind of more complex end of the spectrum. They are things you need to think about. And then the final piece that I think is becoming kind of more and more relevant today is... I think that one of the things that we have to be careful of is that we don't approach every hernia with, you know, a nuclear bomb slash bazooka hernia approach. And it is okay to do smaller operations for smaller hernias that have a reasonably high success rate. And if those fail, we can approach things with some of our more advanced reconstructive techniques. But often, I think some of those are getting pulled out way earlier on the hernia spectrum than perhaps need to be.
Chad Ball 26:21
Yeah, you know, the quality of life comment I think that you made is really important, maybe to reiterate and to remember for us. Because I think, you know, certainly a lot of us will look at the technical challenge of a given scenario. And we do have to keep that in mind and really go deep with the patients in terms of how this is impacting their quality of life. And, you know, for me, I'm sort of lucky, I think, in some ways, because I say, you know what, this isn't liver cancer, this isn't pancreas cancer, you're not going to die because of this. Most times. And so, it's really convinced me how it impacts your quality. So, I totally agree with you, for sure. I'm curious if you could technically, maybe categorize and give us a framework for how you view and how you select, really, the bread-and-butter operations that surround us now, respecting the evolution of this whole field over time. So, things like traditional hernia repair, maybe anterior component separation, modified Memphis reconstruction, component separation, TAR, retrorectus, and so on. How do you view all that and teach that?
Michael Rosen 27:32
Sure. So first of all, even kind of early on the spectrum, I think, for whatever reason, this has become kind of a [inaudible]. So, my current practice today is, you know, smaller isn't really a great definition. But let's just for the sake of argument say, less than five centimeters, and people without an incredibly hostile abdomen, and, you know, aren't particularly thin rooms, where they're going to notice the bulge. Which is probably the lion's share of most people's hernias. It's not often what I see, I see people further down the spectrum. But I always just like to put a plug in for that. For all of those types of hernias, I think a laparoscopic IPOM is perfectly appropriate. I actually for obese people, I don't even close the defect anymore. I just put a wide piece of mash. And I think that they do just fine. It's an outpatient procedure. And I think they do great. And I think that, you know, nothing's perfect, but I think that's a great operation for those people. And that certainly is a great first step, or as the defects get wider, certainly probably like, you know, eight, seven meters or so, that I'm going to start to think about wanting to put their muscles back together. And for me, the majority of time, it's going to be an open operation. I think we're talking about robotics later, but I'm not a big robotic guy. But I think that's, you know, potentially having more and more of a role as we get more and more experienced with that. But for me, you know, my approach to that is always start small and go bigger and the first operation and the ones that should be done the most for the smaller type hernias would just be a standard Reeves type repair, where you just go retro muscular, stop at the linea seminarists. And as long as the posterior sheath closes without tension, I think you should be done. And most the time it's a nice wide piece of mash, close up the muscles afterwards, and you can be done. I think, you know, as the hernias get bigger, and this is probably one of the... if I can make one big take home point for everybody that might be a little bit novel. It's taken me almost 1000 hours to kind of finally appreciate this. But you know, the real reason that we do a TAR and cut the transverse abdominus muscle has nothing to do with getting the anterior fascia close. It actually has everything to do with getting the posterior sheath closed without tension. And then being also able to put a wider piece of mesh because we can access the retro perineal. So, one of the things that we're certainly seeing a lot more of now is people are, you know, experimenting with some of these retro muscular repairs. In particular, they're doing, you know, some of these robotic approaches where they're getting tension on the posterior sheath. What we are seeing are a lot more interstitial hernias where there's breakdown of the posterior sheath, and you get bowel that herniates through the posterior sheath and starts to communicate with the unprotected mesh while the anterior sheath is intact. And the reason why it's so important to understand kind of what each step is and why you're doing it is because if you're doing potentially a robotic tap, and you can't get the posterior sheath closed, instead of hogging it together, that's why you want to cut the transverse abdominus muscle. is to allow that to come back together without tension and the anterior fascia, probably the most advanced or from the anterior fasia just come from once you divide the posterior rectus sheath at the linea alba. So, I think not only understand the anatomy, but understand the contributions of each anatomic layer to the abdominal wall and its function and abdominal reconstruction is super important. To get yourself out of common problems in the operating room and prevent potential complication.
Ameer Farooq 31:25
You kind of briefly touched on the sort of the robotic MIS approaches to some of these hernias. How do you frame that for yourself when you're seeing a patient? In terms of an approach: open versus robotic? Or laparoscopic techniques, something like that. You know, in Canada, as you probably know, we don't have access to the robot. So, it's a bit of a theoretical question for us here in Canada. But I am curious how you use that as an arsenal in your own bag of tricks?
Michael Rosen 31:54
Yeah, so listen, I personally don't do any robotic abdominal reconstruction. There's a lot of reasons for that. I have three partners now who do it. It's a pretty limited resource for us at the clinic. And so we really need to kind of have specialists and not have everybody dabbling in it. And my partners have three ongoing randomized control trials. So, we're pretty religious about if we're using it. We're actually trying to evaluate it to see, you know, where are its advantages. I think, in general, I think the robot has provided a lot of excitement in the field of hernia surgery. And so, for that, I think that's great. And I look forward to seeing where it fits in the armamentarium. I think like everything that's new, there's a lot of marketing forces, there's a lot of kind of key opinion leaders who are real, you know, experts in their craft, who are promoting the technique. So, one of the things that concerns me is when surgeons go on a minimally invasive platform, their threshold to do aggressive things is lowered. So often to do an open TAR over the years, I've noticed that people just won't do it. And it's just there's a resistance, and kind of a concern of causing harm or morbidity. But when doing a laparoscopic robotically, I think that that threshold goes down. And I think the complexity of these cases cannot be overstated. And there's a general feeling and somewhat promoted I believe that the robot makes you a better surgeon. And I think that's a fallacy. I think that if you're a good surgeon, the robot can be used to do different things. But it won't allow you to do things that you can't do open, that you can't do laparoscopically. At least in my opinion, that hasn't been proven yet. So, my biggest concern about robotic ab walls, it's being heavily promoted in the US. It is a growth spot for intuitive, which is the only maker of the robot currently. And so, what's happening is that many, many more people are doing these robotic hernias. And now we're starting to see as these things catch up, some complications I've never seen in my whole life for you know, two- or three-centimeter hernias. While it's theoretically nice to get the mesh outside the peritoneal cavity. The consequences of doing that dissection are yet to be proven in kind of the real-world general surgeon's hands that are doing this. So again, like I said, there's three surgeons at my place to do them. They're all fantastic robotic surgeons, they're all doing clinical trials to kind of assess where it is. And on a personal note, they all know that the minute they show me that there is some clinical advantage to doing something on the robot over my standard way that I'm going to learn how to do it and apply it to those patients. But as of yet, like most other things, all the clinical trials show is it takes longer and cost more money. And there's not a patient benefit. So, you know, it's interesting. I love talking with you guys in Canada, because in many ways, kind of the clinic is not quite that extreme, but it's such that there's limited resources, and they're very strict with who has access and whatnot. And so I think that that avoids some of the marketing strain, that many folks. The societal pressure that is pushed on many surgeons in the US to kind of use things for the marketing perspective than like, perhaps what's best for patients.
Chad Ball 35:40
That makes a lot of sense. I was wondering, Mike, if you could quickly walk us through, you know, you're sort of first level of the three levels you talked about, which is the gastrointestinal work. So how do you generally frame or approach a patient perhaps with an ileostomy? Or a colostomy? How do you approach somebody with an intra cutaneous or enteroatmospheric fistula? And then I was just hoping you could comment on the relatively current utility or non-utility of botox.
Michael Rosen 36:11
So let me start with the easy one first. So, currently I have no rule for Botox. I think that actually is another concerning thing. So just in fairness, I used Botox about 10 years ago for what people are using it for today. And thought, wow, like for the really, really big hernias, it's going to help me close. Botox is like many other adjuncts, you know. In surgery, when you don't need it, it works fantastic. And when you really need it, it doesn't really work. It's sad but true. So, you know, when I look at almost everything that people show me with Botox, those are hernias that I would close 100 out of 100 times with a standard, you know, TAR type approach, and most of those patients are getting it anyway. So, until there's a randomized control trial that shows in a group of people who would not be able to be close, and we have a way to measure that now, with the volume ratios and kind of loss of domain measurements, but in those people, that it allows you to close the fascia or improve some outcome, or it allows you to avoid doing component separations in patients with equivalent defects. And it was blinded. To me, it's $3,000 a patient, you know. There's six of us to do, probably between four and six of these a week. So, it would be staggering, if we all decide to use Botox, how much money that would add. So again, just to kind of reiterate, one of the things that concerns me, now I'm seeing people from all over the world that we're told by other surgeons, oh, you can't do your operation without Botox. And I don't know how we got to this point. And so, I think that it's just really critical that we all take a moment. And you know, if you just kind of do the operation right, you don't really need a lot of these other special type things. So that's the Botox thing. And then the other thing. So as far as stomas go, so number one first question with every stoma is, can it come down? Because there's no question that the outcomes of a reconstruction without a stoma are substantially better than any reconstruction with the stoma there. So, assuming you can come down, I think best thing in the world is take it down, and then come back and fix the hernia another day. But if you want to do it simultaneously, I think that's acceptable as well. There's mounting data to say that's okay. If the stoma won't come down, then we're actually doing a randomized control trial looking at retro muscular sugarbaker versus retro muscular keyhole. It's 145 patients, and we're at about 110 patients right now. So, we're actually getting close to the end. So, we'll be able to hopefully add something to that. I don't know what the data shows yet. But what I can tell you is, it's a morbid operation with a high complication rate, even in people that do it at very, very high volume. So, I think the general theme of if you can avoid operating on parastomals is probably holds true unless one of these techniques shows its superiority long term. And then between the two, you know, it's kind of dealer's choice. I think they're both okay. But again, neither one of them are perfect. And then for the fistula side of things, that's a lot different. I think a lot more thought needs to go on fistulas and kind of the understanding why people have an enteroatmospheric fistula is really important, because if they have it from a primary GI problem, like Crohn's disease and whatnot. That's one approach versus if they have it from potentially a primary abdominal wall failure, like an evisceration, that's a different approach. Because if it's a Crohn's patient, you're probably better off addressing the fistula issue, and just primarily closing. Versus if it's a primary abdominal wall failure patient, then I think you're better off, you're going to have to address the abdominal wall in some more definitive way than just hogging it together, because they probably got the fistula in the first place because of that. So in that group of patients, I tend to do simultaneous ab wall reconstructions. Obviously, after pre-op optimization with nutritional supplementation necessary, good stoma care. And, you know, reasonable expectations and whatnot.
Ameer Farooq 40:50
We did want to hit one more topic with you because I think the quote unquote humble inguinal hernia or groin hernia is such a underappreciated topic. Again, I think we do have to ask the question, when do you do inguinal hernias lat versus open? Obviously, again, robotics is not, you know, a factor here in Canada. But in your mind, when you get a patient with an inguinal hernia, how do you approach that? When would you do it lap? When would you do it open?
Michael Rosen 41:16
So, I appreciate the question, because I think that it's really, really important. And maybe I'll start by answering it with a more broad answer beyond just what I would do, but I'll justify why I do what I do. And just, I think number one, I'm going to borrow something from Chad. An inguinal hernia is not pancreatic cancer. It is unlikely to kill the patient, you do not need to make it more complicated than it needs to be. And the reality of mo hernia is that almost every randomized control trial has ever shown is that if you know how to do one of the operations well, that's what you should do the majority of time. And obviously, there will be some patients for all of those types of approaches that are not candidates. And you should consider if they're a candidate for something better, sending it to somebody else. So, I think open tension free inguinal hernia repairs still have a role. I'm actually headed up to Mickey Reinhorn, who does a ton of Shouldices in Boston. We actually spent some time in the Shouldice clinic. I'm going to watch it because I want to learn how to do that. Because there's so much aversion to mesh now that I just want to be able to offer it for my patients. I think a lichtenstein is a perfectly good operation. If you know how to do well. But there are subtleties to it. And again, it could be a technically challenging operation as you point out. It's not easy. You have to reconstruct the anatomy; you have to respect tissue planes. And you can cause problems, lifetime problems. And then I think the minimally invasive approaches, whether it's lap or robotic, temp or tap, I think they're a much more advanced approach. I think of all the cases that I teach residents and fellows. For me personally, it is the most frustrating case to teach somebody how to do. I would say that probably most of our fellows would say at the end, they would rather do a paraesophageal hernia than a lap inguinal, because I am very particular about how it's done and being in the right plane. I think if you know how to do a lapping one, well, it's a great operation. But I think for most people, it's not worth trying to ascend the learning curve to do that, because I think it's quite high. I think that you know, the question about whether the robot shortens that learning curve is unanswered and should be answered, because it is possible that people are sitting comfortably in a chair operating with a three-dimensional view while doing an inadequate operation. So, I think we have to be careful before we say that it does that until we actually study that. I think it's possible to actually prove that one way or the other. So, my answer to inguinal hernia is have a way to do it, do what you do best. Now me personally, you know, I consider myself a minimally invasive surgeon. You know, maybe I've done close to 800 lapping, I think I'm pretty good at that operation. And to me, the mesh looks the most reproducible at the end of that operation when I do it. So, that's what I like to do. But if somebody had prior abdominal surgery, prior lapping, I do an opening well. I think i think I'm very good at it. I do a Lichtenstein and if people have had a prior open surgery, then I do it lap. And I think for really young people, I like to do it lap, because they need to get back to activities a little bit quicker. But for older people I think open is perfectly fine. But again, the idea of like debating which one's better, I think we should move past that and just make sure that you have the way that you do it best, and feel confident that you're taking good care of patients when you do it that way.
Ameer Farooq 44:55
Dr. Rosen, can you walk us through how you, just broad strokes, as Dr. Ball says, at a 30,000-foot level, how you approach a lap inguinal hernia repair? What are the kind of key steps in your mind? And you know, you've mentioned this before that, you know, it's a very hard operation to teach. What are the things that in your view people do wrong or could do better when doing a lap inguinal hernia repair?
Michael Rosen 45:21
Sure. So, I think first of all, if you're learning it, you got to pick the right patient. And an obese guy with a lot of retroperitoneal fat is horrific. You know, reduce, pelvic stuff, so pick the right person. Second of all, for the dissection itself, I think one of the keys to doing it to me, or the way I like to teach it, it's a dissection of the inferior epigastric vessels. And so, I do my dissection, I start my flap very high up, actually at the confluence of the medial vocal folds almost at the umbilicus. Because I like to have a lot of room to work. And I go straight across. I don't curve down to the internal ring, so I have a big pocket. And then I do a medial dissection to Cooper's to the inferior epigastric. Because if you think about it, when I'm teaching a resident how to do this, if your medial to the inferior epigastric, all moves and wipes are medial. Away from the iliacs. And then I go lateral. All moves are lateral, so you're not ever going to get lost on the inferior epigastric. The other small trick, but from just doing a bunch of TAR if you learn this, is in the retro muscular space, there's a pre-transversalis so the rectus muscle, the transversalis, and then a preperitoneal. The transversalis to the fascia to the preperitoneal. And that's a distinct plane below the umbilicus. And if you ever do a tap and you blow the balloon up, you know that if you see the rectus muscle, the beefy part of the rectus muscle, it's an easier dissection going lateral, because you're below the transversalis fascia that inserts into the linea semilunaris. If you see the big red beefy muscle, it's harder to get out lateral because you've got to bust through the transversalis fascia at its insertion point in the linea semilunaris. If you blow up the muscle, and you see like thin little white flimsy stuff on the muscle in between your balloon and the muscle, you're actually in the pre-peritoneal plane, and much, much easier to get out lateral. So I think the most important thing people don't realize is that there are planes in here. And when I watch most people do this operation, what they're really doing is they're jumping in and out of planes, and not dissecting in the planes. The final part is dissect to a landmark. So, Cooper's is my first landmark. The chord structures are my second landmark. Inferior epigastric is my third landmark. Reduce the chord off the structures, and then you know, you can put your mesh in. So, I think, then the final piece about the mesh I should say is, if you are struggling with the mesh, and I don't think the mesh should ever be less than 12 by 15 centimeters, if you're struggling with the mesh, you didn't make an adequate pocket. It's laparoscopic skill sets. You got to make a bigger pocket.
Chad Ball 48:16
I was wondering if we could switch gears here for a little bit and talk about the dreaded chronic pain. I'm curious, both at the front end and the back end what your approach is. So how do you address and approach the patient that comes into clinic? Maybe with a small growing hernia and has significant chronic pain? How do you assess those folks? And who do you offer an operation to and who don' you? And then I'm curious also at the back end, so a classic patient maybe without chronic pain comes in and you fix their hernia and they end up you know, with the dreaded chronic pain a scenario thereafter and that small percentage of them. I'm curious how you consent those patients for that potential complication and how you address it at the back end as well.
Michael Rosen 49:06
Sure. So, the first thing if I could really be clear on is, if you have a patient that comes into your office, and their primary care physician felt something when they coughed. And when you talk to that patient, they have no symptoms and you don't see an obvious bulge on exam, do not put mesh in that patient. That that is the most common setup for chronic groin pain is somebody who was asymptomatic who probably didn't even have a hernia. And we go in and think we're like curing people in this terrible hernia problem. And we create a chronic mesh situation. That's probably the number one person I see, is chronic pains. Second is the kind of the patient that you've brought up, which is somebody has a small hernia, but significant pain related to that. That is a red flag. That, you know, to be honest, I'm still troubled by why inguinal hernias cause pain at all. So, I try to be pretty upfront with people and say, hey, look, you know, we can fix this. But this is not inguinal hernia pain. So, if I'm really worried about that, and I got a bad feeling about that, then what I'll often do is get what's called a, we have a dynamic ultrasound, we have a very engaged ultrasonographer, who's a musculoskeletal specialist, who really kind of understands this anatomy. And what they could do is they'll look and tell you whether there's an abductor tear, whether there's any other musculoskeletal issues, whether there's any neuritis, any inflammation of the nerves, or any of those types of things, or whether when they're touching the hernias it's reproducing that pain. I think that's really worth it, because small hernias should not cause substantial groin pain. And again, there's good evidence out there. Some of this from Todd Heniford that shows the number one predictor of post op pain is pre op pain, typically in young folks. The final thing is when somebody comes in with chronic pain, I think that, you know, unfortunately, what we suffered from in hernia surgery, but I think we're getting better at is acknowledging how hard it is to do this, and how hard it is to get good results. And I think as we study this more, we realize that, you know, depending on how you define it, you know, life limiting pain, for inguinal hernias is probably 2%. And you know, that's 2% of a very large number. So, it's a common problem. And, you know, there's often a lot of things going on in these patients that are very, very complicated, especially the ones that had this pain for a long time. And they are extremely debilitating, whether it's all because of the hernia pain or not, it's really hard to kind of figure that out. I think, number one, if you as a surgeon caused the pain, then there's often some emotional, you know, attachment to that. And you should have a very low threshold to have somebody else get involved with helping you. I mean, there's specialty centers now David Chen at UCLA has it, and my partner, David Krpata, where this is essentially all these guys do now. And they have a whole multi-specialty group, where people come in, they meet the behavioral scientists, they meet the interventional radiologists, they get the ultrasound, they meet the surgeon, and they really kind of get a multi-specialty approach, which I really think these people need. And kind of then to get into the algorithm of dealing with that, I think that probably the general theme is that what I tell patients is, hey, look, everything I do hurts. You know, I use a knife to make you better. And anything I do can cause pain. And that's what you're here for is because I did an operation, you have pain. So we want to put the brakes on rushing back in to try and surgically treat pain. And I think you know, doing different things like injections, particularly ultrasound guidance to try and pinpoint things, sometimes physical therapy, you know, 10 units and whatnot are all reasonable. But unfortunately, what is becoming more and more common is in today's world, particularly because of the barrage of commercials and litigation, a lot of people are not going to be satisfied until you take out that mesh. And we have to do a fair bit of that. And I think our results if you look across the board, probably 60% of the patients feel improvement, not to zero, but improvement. And about 40% of people are not helped by doing that. So, you know, it's a tough problem. And it's a very you know, morbid group of patients, who are just...some of these patients are suicidal. It's just unbelievable.
Ameer Farooq 53:43
Yeah, obviously, it's a big problem and something that we're going to have to kind of come to grips with and maybe present that a bit better when we are actually seeing these patients initially. And really make sure that people understand that is going to be a big problem. When you go to do these neurectomies, or not neurectomies but you know, mesh excisions, are you doing anything with the hernia at that time? Are you just sort of accepting that they're going to have another hernia? When you're actually going back in to surgically excise these meshes, how do you kind of approach that?
Michael Rosen 54:17
I've changed over the years. What I used to do was if they had a prior pain after an anterior mesh, I would go in laparoscopically, I would put a piece of mesh and then I would go for the front and take everything out. There's often a hole in the abdominal wall once you do that. My partner Dave has kind of taught me that that's probably not a great idea because you still then have a foreign body in there. And you know, you're never going to be able to kind of figure out whether or not you made the pain better. So, what I do now, whether it's done, you know whether they've had a lap or robotic piece of mesh or an open mesh is, if I go in open, anteriorly, I will just take out the mesh. And I'll typically do a proceeding to close things up. Often things are so scarred in that they don't recur. We don't have enough long-term data. I'm sure there is some recurrence rate, but it's not astronomical. And I often tell these patients, you might want to trade a hernia for a mesh repair and potential chronic pain, and often they'll deal with that. Interestingly, and this is what I think, again, not enough evidence really proves this yet, but a lot of the laparoscopic and particularly the robotic mesh repairs, when you go back in and take it out, there was no hernia there in the first place. Or there's at least no hernia when I go back. And so we don't do anything. And most of these people don't actually get a hernia, which kind of makes me think of that other patient I was talking about, which is the person who the PCP thought they felt something. And then, you know, we all feel obligated to fix it. When in reality, they should have just been watched.
Ameer Farooq 55:54
The sort of final clinical topic we want to talk to you about was briefly just to talk about your approach to the emergent incarcerated hernia. When you're thinking about trying to fix these, what's your sort of overview? Are you trying to reduce everyone in emerg? Are you bringing them all to the operating room? And then when you have them in the operating room, what's your preferred way of dealing with these? Again, are you doing these open, or lap? And then finally, you know, if you have to do a bowel resection, do you put mesh or not?
Michael Rosen 56:27
Right, so a couple kind of very broad comments on that is number one, I think every hernia should be tried to be reduced. If the bowel is dead, you're not gonna be able to push it back in. A dead bowel, you can't get it back in, it'll be impossible. So, I try and reduce everything. Number two, you know, kind of the, this is the way I think about it to be honest. When I take acute care call when I'm doing it, whatnot, cause I have all the tools in the world to fix this. But what I'd like people to think about is, at the end of the day, if you're an ab wall reconstruction surgeon, you're basically a roofer. And you're going to fix holes in people's roofs. And so there's two scenarios that people call you to fix a hole in their roof. There's a thunder and lightning storm and a tree fell on the roof and the water is pouring in. If you call the roofer, they're not going to go out there and rebuild the roof in the thunder and lightning storm, they're going to put a tarp and tell you to call back when it's a nice sunny day. And so, when it's a nice sunny day, you're gonna go out there and make a beautiful roof. So, anytime I'm called into any situation, or I'm thinking about anything, particularly emergent, my thoughts to myself, is this a storm, or is this a nice, beautiful day. And if it's a storm, either close primarily, I'll typically use micro mesh as a bridge, let them get a hernia, and I have a million things I could do in the future to try and repair that. If I feel like it's, you know, maybe a cloudy day or not much of a chance of rain or it's a nice sunny day, then I will at times go on. But one of the things I like people to kind of realize is you have to like... I've done a lot of these operations. So, for me, it probably takes about an hour and a half to do a TAR pretty reliably. So when I think about doing that, it's like an hour and a half of added OR time. If you're talking about five or six hours of added OR time, that should be a different threshold. It probably shouldn't be done simultaneously, because you're talking about four or five liters of fluid, anaesthetic, diaphragm issues, recovery issues, wound morbidity. So again, I think depending on where you are in your experience, should guide you because you know, again, this isn't cancer. This doesn't all have to be done that day, you could always come back another day and fix people's abdominal wall. And what I often don't want to do is burn a bridge for future things. And so, for me, if I'm doing a bowel resection or something, I think it's you know, I certainly will put a medium weight synthetic mesh in that situation. Today I don't think that biological absorber synthetics are wrong in that scenario. But again, if I'm going to reconstruct them, they're going to get synthetic mesh for me, but I wouldn't fault people who did it otherwise. But if it's a bowel resection, and things are really bad, and it's going terrible, then I have no qualms bailing on the hernia repair and kind of like I said, those three layers in the beginning, just to dress the GI part today, and come back another day when you can take your time and fix their ab wall. So again, I think probably, you know, the hardest thing in the world to do as a surgeon is to do less. And I think that comes with you know from years of doing the wrong thing too aggressively. And realizing when it's you know, it's just okay to move the runner over, or you know, not everything needs to be a Grand Slam.
Chad Ball 59:48
You know, I add a comment and then a question and my comment is, I think all of us again, globally would like to thank you. You know, the traditional statement that hernia research is a bit of an oxymoron. Certainly, has been true, I would argue until you. And you've really, you and your group really over the years have really taken that to heart, I think. And not only as you talk about clinically finding a niche as you start off in your career, but you've really done that on the on the research side in an area that really had a paucity of good material. So, we thank you for that. I'm curious if you would just touch on the amazing work you've done in that realm with regard to multicenter Quality Collaboratives in the space of hernia and abdominal wall reconstruction. Clearly very powerful. Clearly, I would think, you can correct me if I'm wrong, but modeled on, you know, trauma care and oncologic care and so on, and really needed. How's that going? And how have you been using that?
Michael Rosen 1:00:49
Well, thank you for the comments. And I think, you know, in the same vein, I think that as you get older in life, one of the things that hopefully people can kind of think about in their respective professions is to move away from trying to prove that the way I'm doing something is best, and actually seek the truth of, you know, what is best. What is best for me might not be best for you, and, you know, understanding everybody's individual approach. And to be honest, until I started the quality collaborative, and kind of, you know, we have almost 500 surgeons, some in solo private practice and others in big academic hospitals, and kind of was able to see the data. What different people's practices were, and have a respect for wow, you know, not everybody does what I do every day, and I don't do what they do every day. It has really, for me been enlightening, rewarding. And kind of, probably most importantly, it's been energizing, to move away from, you know, as I always say, like a lot of young surgeons, a lot of what we write about is kind of look what I can do. And that's okay. I don't think that's a negative thing. But eventually, we have to move to kind of what's best for everybody else. And that's a moving target. And, you know, I have to say, like our group, we tried really, really hard to just kind of seek the truth, and whatever the truth is, is what we're all just gonna do, whether we agree with it, but you know, that was our bias. And I think once you kind of transition into that, it's a huge thing. And I think that, for us as surgeons, it's really hard. It's not our natural instincts to think about collaborating. A lot of our instincts are about kind of self-preservation, self-promotion, and, you know, our own technical skills and whatnot. Which is normal. I think, as a group, we have to move that dial and kind of think more of a patient centered approach, which is just what's best for our patients. When we're the ones doing.
Ameer Farooq 1:02:53
Dr. Rosen, you've given us some amazing pieces of advice already throughout the chat we've had today. From Jeff Ponsky's "pursue things that nobody else wants to do", living life on the extreme. It's been fascinating and really powerful advice. But one of the things we like to ask all of our guests at the end of the show is, if you could go back in time and give yourself advice as a chief resident, or perhaps even as an early attending, what would your advice be to yourself, having now gone through what you've gone through?
Michael Rosen 1:03:23
Yeah, so I think probably one of the...if I can look back on myself and kind of divide my career in the first 10 years and the last 10 years, my advice to myself back then, and everybody else, but especially me, would be collaborative. Be confident enough to listen to others. Be thoughtful enough to be introspective and wonder if maybe they're right. And you know, you don't have all the answers. And finally, just because something works in the short term, doesn't mean it's a good idea in the long term. So, take your time before you think you've figured it all out. Because I certainly liked as I mentioned at the beginning, I like to live my life on extremes. And I like to be definitive about everything I do. And one of the things of kind of doing higher quality research and having the courage to ask some of these questions and answer them with answers that I was not anticipating, is kind of coping with that. And understanding that really is a good thing. But it takes kind of confidence to be able to be collaborative and be open minded in that. And I think that it's much less constraining in your academic and professional life when you have that approach. And I think no matter what, it takes you a little bit of time to get there. But I certainly wish I would have got there a lot sooner. But I'm happy that I'm there now.
Ameer Farooq 1:04:59
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your comments and feedback. So, feel free to email us at [email protected] or connect with us on Twitter @CanJSurg. Thanks again.