# Low Cardiac Output — GCMD Library living collection

Experts: Dr. Jeffrey Ponsky, Dr. Michael Rosen

Updated: n/a · 1 episodes · 63 cited statements

## Episodes
### In-Depth Reviews
- [Inguinal Hernia: Adult](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441) — podcast · 31:02 · [machine version](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=0) Introduction and Asymptomatic Hernia Management (Ep 1)
- [2:11](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=131) Evidence for Watchful Waiting: The Fitzgibbons Study (Ep 1)
- [5:00](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=300) High-Risk Patients and Non-Operative Management (Ep 1)
- [7:52](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=472) Selecting the Operative Approach: Open vs Laparoscopic (Ep 1)
- [10:17](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=617) TAPP vs TEP: Laparoscopic Technique Comparison (Ep 1)
- [11:41](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=701) Patient Counseling: Laparoscopic vs Open Benefits and Risks (Ep 1)
- [14:58](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=898) Contraindications to Laparoscopy (Ep 1)
- [16:56](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1016) Laparoscopic Technique: Dissection Principles (Ep 1)
- [20:26](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1226) Mesh Selection and Sizing (Ep 1)
- [23:43](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1423) Mesh Fixation Techniques (Ep 1)
- [24:26](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1466) Open Repair: Lichtenstein and Contaminated Fields (Ep 1)
- [25:45](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1545) Femoral Hernia Repair Technique (Ep 1)
- [28:04](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1684) Special Situations: Recurrent, Bilateral, and Incarcerated Hernias (Ep 1)
- [30:05](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1805) Summary and Conclusion (Ep 1)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "In the Fitzgibbons VA study of minimally symptomatic to asymptomatic inguinal hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration or strangulation) requiring operation was 0.3% over 2 years." — Michael Rosen (epidemiological) [Ep 1 · 3:30](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=210)
- "In the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years." — Michael Rosen (epidemiological) [Ep 1 · 4:11](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=251)
- "In long-term follow-up of the Fitzgibbons study, almost three-fifths of patients in the observation group developed symptoms requiring operation by 5 years." — Michael Rosen (epidemiological) [Ep 1 · 4:21](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=261)
- "For an 89-year-old patient with an asymptomatic hernia, watchful waiting is acceptable because the odds are they may not develop symptoms over their remaining lifespan." — Michael Rosen (opinion) [Ep 1 · 4:33](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=273)
- "For younger patients with asymptomatic hernias, the odds are against them living the rest of their life without the hernia becoming symptomatic, so repair should be recommended when the time is right." — Michael Rosen (opinion) [Ep 1 · 4:36](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=276)
- "Inguinal hernia repairs can be performed under local anesthesia in high-risk patients." — Michael Rosen (clinical) [Ep 1 · 6:06](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=366)
- "For symptomatic hernias in high-risk patients, it is much worse for them to present with an emergency problem in the middle of the night, which could be life-threatening, so they should still be offered repair." — Michael Rosen (opinion) [Ep 1 · 6:06](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=366)
- "For unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support." — Michael Rosen (clinical) [Ep 1 · 7:56](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=476)
- "The best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature." — Michael Rosen (opinion) [Ep 1 · 8:29](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=509)
- "The learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required." — Michael Rosen (epidemiological) [Ep 1 · 9:04](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=544)
- "In laparoscopic inguinal hernia repair, the mesh is placed away from the nerves, and the risk of chronic pain is lower than in open inguinal hernia repair when done correctly." — Michael Rosen (clinical) [Ep 1 · 9:18](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=558)
- "Chronic pain after open inguinal hernia repair can occur due to technical problems or simply due to mesh laying on the nerves, and affected patients are absolutely miserable." — Michael Rosen (clinical) [Ep 1 · 9:51](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=591)
- "For young, healthy patients with unilateral hernias who are not anesthetic risks, laparoscopic repair is preferred by Dr. Rosen if the surgeon is past the learning curve." — Michael Rosen (opinion) [Ep 1 · 9:04](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=544)
- "TAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes." — Michael Rosen (epidemiological) [Ep 1 · 10:45](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=645)
- "TEP repair requires use of a balloon dissector, which is more expensive, and provides a smaller working space but perhaps easier angles to operate with." — Michael Rosen (clinical) [Ep 1 · 10:58](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=658)
- "TAPP repair provides a better view and larger working space, and makes it easier for surgeons early in their learning curve to look intraperitoneally and confirm hernia reduction." — Michael Rosen (clinical) [Ep 1 · 11:09](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=669)
- "TAPP and TEP ultimately work in the same anatomical space—one enters through the front door, one through the ceiling—and should result in the same operation." — Michael Rosen (clinical) [Ep 1 · 11:26](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=686)
- "Laparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair." — Michael Rosen (clinical) [Ep 1 · 12:23](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=743)
- "Laparoscopic inguinal hernia repair carries a risk of intestinal injury and injury to major blood vessels because the operation is performed near these structures, but this risk should be incredibly low if the surgeon knows the planes and operates safely." — Michael Rosen (clinical) [Ep 1 · 12:45](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=765)
- "In elderly patients with any anesthetic risk or anyone on anticoagulation who needs to restart quickly, Dr. Rosen prefers open repair because he does not want to dissect the retroperitoneal space in these patients." — Michael Rosen (opinion) [Ep 1 · 13:28](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=808)
- "In a 78-year-old patient with a symptomatic hernia on one side and an asymptomatic hernia discovered laparoscopically on the other side, Dr. Rosen does not fix the asymptomatic side, citing concerns about doubling anesthetic time and increasing hematoma risk." — Michael Rosen (opinion) [Ep 1 · 14:10](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=850)
- "Pneumoperitoneum is rarely a problem in patients with reduced cardiac capacity as long as insufflation is done slowly, pressures are kept low, and the patient is positioned in Trendelenburg to help cardiac return." — Michael Rosen (clinical) [Ep 1 · 15:17](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=917)
- "The benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile." — Michael Rosen (opinion) [Ep 1 · 15:39](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=939)
- "Surgeons must check their minimally invasive ego at the door and ensure they can also perform open inguinal hernias or refer to someone who can, rather than pushing laparoscopy in sick comorbid patients simply because it is their go-to approach." — Michael Rosen (opinion) [Ep 1 · 15:55](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=955)
- "Previous lower abdominal surgery is a contraindication to laparoscopic inguinal hernia repair in Dr. Rosen's practice because it increases the risk of enterotomy and OR time." — Michael Rosen (opinion) [Ep 1 · 16:24](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=984)
- "Previous prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs." — Michael Rosen (opinion) [Ep 1 · 16:42](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1002)
- "Basic tenets of laparoscopic inguinal hernia repair include achieving a wide dissection plane, with parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly) being the most critical element." — Michael Rosen (clinical) [Ep 1 · 17:52](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1072)
- "Parietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs." — Michael Rosen (clinical) [Ep 1 · 18:15](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1095)
- "The length of parietalization is critical because it prevents the peritoneum from coming under the mesh and going back out to the defect, which is the mechanism of recurrence." — Michael Rosen (clinical) [Ep 1 · 18:27](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1107)
- "The inferior dissection is the Achilles heel of any laparoscopic inguinal hernia repair because it is awkward to view, surgeons fear making holes in the peritoneum, and it requires dissection very close to the vessels." — Michael Rosen (clinical) [Ep 1 · 18:53](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1133)
- "When surgeons do not take the peritoneum far enough back inferiorly, they tend to use a smaller piece of mesh, which is problematic." — Michael Rosen (clinical) [Ep 1 · 19:03](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1143)
- "All mesh contracts to some degree and can move." — Michael Rosen (clinical) [Ep 1 · 19:30](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1170)
- "According to Stoppa's original descriptions, for a unilateral inguinal hernia, surgeons should never use less than a 15 by 15 centimeter (6 by 6 inch) piece of mesh, which is much bigger than the vast majority of laparoscopic pre-formed meshes being placed." — Michael Rosen (clinical) [Ep 1 · 19:40](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1180)
- "For large direct inguinal hernias, mesh choice should change and surgeons should use a heavier weight material." — Michael Rosen (opinion) [Ep 1 · 20:26](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1226)
- "Heavyweight mesh is approximately 90 grams per meter squared (e.g., Marlex or Prolene)." — Michael Rosen (clinical) [Ep 1 · 21:37](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1297)
- "Midweight mesh is between 40 to 50 grams per meter squared." — Michael Rosen (clinical) [Ep 1 · 21:57](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1317)
- "Lightweight mesh (Ultrapro) is less than 30 grams per meter squared, starting heavier but degrading over time to about 28 grams per meter squared." — Michael Rosen (clinical) [Ep 1 · 21:57](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1317)
- "Mesh weight categories (heavyweight, midweight, lightweight) were defined by marketing companies, not based on science." — Michael Rosen (clinical) [Ep 1 · 21:37](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1297)
- "Advantages of lighter weight mesh include less foreign body, less palpability, and potentially less contraction because it ingrows more." — Michael Rosen (clinical) [Ep 1 · 22:16](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1336)
- "Disadvantages of lightweight mesh include having half the material, and in direct hernias where the mesh bridges and muscles never come together, the mesh is at risk for fracturing, with reports now showing central mesh failures." — Michael Rosen (clinical) [Ep 1 · 22:23](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1343)
- "Heavier weight mesh rarely breaks, but patients sometimes feel it in their groin if there are wrinkles or buckles, which can cause issues." — Michael Rosen (clinical) [Ep 1 · 22:42](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1362)
- "Pre-formed meshes for inguinal hernia anatomy are technically easier to place but surgeons commonly downsize to a much smaller piece of mesh, which is problematic." — Michael Rosen (clinical) [Ep 1 · 22:51](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1371)
- "For laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh because the entire myopectineal orifice needs to be covered." — Michael Rosen (opinion) [Ep 1 · 23:08](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1388)
- "If the mesh is too big during laparoscopic inguinal hernia repair, the problem is not the mesh size but inadequate dissection of the space." — Michael Rosen (clinical) [Ep 1 · 23:24](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1404)
- "Dr. Rosen believes mesh should be fixed in laparoscopic inguinal hernia repair and uses ProTack, though some surgeons use glue or no fixation." — Michael Rosen (opinion) [Ep 1 · 23:53](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1433)
- "Even surgeons who advocate no fixation will selectively use fixation for large direct hernias." — Michael Rosen (clinical) [Ep 1 · 23:59](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1439)
- "There is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to non-absorbable fixation." — Michael Rosen (epidemiological) [Ep 1 · 24:10](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1450)
- "If a tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself." — Michael Rosen (clinical) [Ep 1 · 24:22](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1462)
- "Dr. Rosen performs Lichtenstein repair as his preferred open inguinal hernia technique." — Michael Rosen (opinion) [Ep 1 · 24:30](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1470)
- "There is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field, with several series in ventral hernias supporting this." — Michael Rosen (epidemiological) [Ep 1 · 24:56](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1496)
- "Depending on the level of contamination and indication, it is also appropriate to perform a Bassini or McVay repair without mesh in contaminated fields." — Michael Rosen (opinion) [Ep 1 · 25:01](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1501)
- "For incarcerated femoral hernias with bowel compromise, Dr. Rosen makes a vertical incision (vascular exposure), dissects onto the hernia sac, and can resect compromised bowel infrainguinally without dividing the inguinal ligament." — Michael Rosen (opinion) [Ep 1 · 25:55](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1555)
- "To gain space for reducing femoral hernia contents without dividing the inguinal ligament, surgeons can release the lacunar ligament medially (which gives off from the inguinal ligament and goes to the pectineal line) to gain an extra 1 centimeter." — Michael Rosen (clinical) [Ep 1 · 26:36](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1596)
- "Dr. Rosen performs a 'reverse McVay' repair for femoral hernias from the infrainguinal approach, sewing the inferior border of the inguinal ligament down to Cooper's ligament starting medially to avoid impinging on the femoral vein." — Michael Rosen (opinion) [Ep 1 · 27:19](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1639)
- "Dr. Rosen does not use mesh plugs in femoral hernia repair because femoral hernias tend to occur in thin women and he has had a DVT occur due to irritation of the femoral vein from the plug." — Michael Rosen (opinion) [Ep 1 · 27:44](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1664)
- "For recurrent inguinal hernias, surgeons should approach from where nobody has been before, or if both spaces have been operated, go where they are most skilled." — Michael Rosen (opinion) [Ep 1 · 28:12](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1692)
- "For known bilateral inguinal hernias in a skilled laparoscopic surgeon's hands, laparoscopy is the preferred approach." — Michael Rosen (opinion) [Ep 1 · 28:31](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1711)
- "Surgeons learning laparoscopic inguinal hernia repair should avoid bilateral and recurrent hernias during their learning curve, even though these patients might benefit most from laparoscopy, because these cases are twice as hard." — Michael Rosen (opinion) [Ep 1 · 28:36](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1716)
- "For large inguinoscrotal hernias, Dr. Rosen now performs all repairs open, whereas when he was younger he did them laparoscopically." — Michael Rosen (opinion) [Ep 1 · 29:10](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1750)
- "For incarcerated hernias that are difficult to reduce, Dr. Rosen puts patients to sleep and reduces the hernia under general anesthesia, then can proceed with TAPP repair." — Michael Rosen (opinion) [Ep 1 · 29:23](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1763)
- "For truly incarcerated hernias, TEP repair is not a good idea because surgeons want the hernia contents out of the sac; TAPP is preferred." — Michael Rosen (opinion) [Ep 1 · 29:30](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1770)
- "Surgeons can laparoscopically cut the internal ring at the 2 o'clock position while watching the epigastric vessels to help reduce an incarcerated hernia." — Michael Rosen (clinical) [Ep 1 · 29:43](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1783)
- "If an incarcerated hernia cannot be reduced laparoscopically, it should be done open, because making holes in the bowel increases the morbidity of the operation unacceptably high." — Michael Rosen (opinion) [Ep 1 · 29:53](https://qa.library.globalcastmd.com/watch/inguinal-hernia-adult-3441?t=1793)

## Changelog
- Sep 9: Summaries and takeaways published for 4 audiences
- Aug 31: 2 doctors auto-found from episode dossiers
- Aug 30: 2 doctors auto-found from episode dossiers
- Aug 30: 2 doctors auto-found from episode dossiers
- Aug 29: 2 doctors auto-found from episode dossiers
- Aug 29: 2 doctors auto-found from episode dossiers
- Aug 29: Collection generated from campaign corpus: 1 items, 1 dossiers, summaries for 2 audience(s)
- Aug 29: Collection reviewed and published
- Aug 29: Collection generated from campaign corpus: 1 items, 1 dossiers, summaries for 0 audience(s)
- Aug 29: Collection generated from campaign corpus: 1 items, 1 dossiers, summaries for 2 audience(s)
- Aug 29: Collection generated from campaign corpus: 1 items, 1 dossiers, summaries for 1 audience(s)

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