Michael Rosen

636 statements · 5 topics

Inguinal Hernia · guest expert Low Cardiac Output · guest expert Sarcoma (Ewing/Rhabdo) · guest expert

Featured statements

I think the disadvantage of it is that you have to operate near the intestines, whereas open, you're in a separate plane. So there is a risk of intestinal injury. There's a risk of injury to the major blood vessels because you're in that area. But again, if you are safe and know those planes, that risk should be incredibly low.

quote · Inguinal Hernia

If you go back and read Stopa's original descriptions, his description, if you were doing a unilateral inguinal hernia was to never use less than a 15 by 15 centimeter piece of mesh or a 6 by 6 inch piece of mesh, which is much bigger than the vast majority of laparoscopic pre-formed meshes or or meshes that are being placed.

quote · Inguinal Hernia

The key, and where I've seen young people get in trouble, and what I've been in trouble myself in this is where you try to make a space and not do a dissection. So this has to be identifying name structures, digging them out in a very systematic fashion, and not being erratic or you get lost quick.

quote · Gastroesophageal Reflux Disease

One of the common mistakes I would make was that I thought I have all this intraabdominal esophageal length, and I would feel the need to wrap all of that. And I think one of the mistakes that people make is they make the wrap too long, uh, and it adds to dysphagia.

quote · Gastroesophageal Reflux Disease

Just remember that anytime somebody stands up and coughs or does a Valsalva, there's always the cord structures that are gonna be giving you an impulse, so you really wanna make sure that you actually see a bulge, and it's a true hernia.

quote · Low Cardiac Output

I think that that surgical skill is critical, and you don't want to be getting an inguinal hernia in the patient's first in the surgeon's first couple laparoscopic inguinal hernia operates because there is a real learning curve.

quote · Low Cardiac Output

Nothing matches these filters — clear the search or widen the filters.

Michael's statements about Gastroesophageal Reflux Disease 100 statements

Open the Gastroesophageal Reflux Disease collection →

Gastroesopheal Reflux Disease

Statement PPIs reduce gastric acid secretion more effectively than H2 blockers and are more convenient as once-daily dosing Open

Statement Mounting data shows that lifetime proton pump inhibitor use has consequences Open

Statement Minimum workup for patients with reflux symptoms requiring chronic PPI therapy includes endoscopy to assess esophagitis and rule out Barrett's esophagus Open

Statement Long-term PPI use in women is associated with osteoporosis risk Open

Statement For PPI efficacy, the medication should be taken within 30 minutes before a meal, not at night before bed or in the morning while skipping breakfast Open

Statement The primary reason for obtaining manometry before anti-reflux surgery is to rule out achalasia, because wrapping a patient with achalasia destroys esophageal function Open

Quotation If you wrap somebody with ankylasia, you have really destroyed their esophageal function. Open

Statement Routine manometry before reflux surgery identifies previously undiagnosed achalasia cases that would have been missed without systematic testing Open

Statement Patients with achalasia can present with heartburn symptoms due to stasis and fermentation of food in the esophagus Open

Statement Manometry findings guide fundoplication type: distal esophageal amplitudes help determine whether to perform a full Nissen wrap versus a partial Toupet wrap Open

Statement One disadvantage of laparoscopic fundoplication compared to open surgery is reduced scar tissue formation; full mediastinal dissection helps create scarring to reduce recurrence rates Open

Statement Nissen fundoplication technique is highly variable among surgeons with poor standardization, making it difficult to reproduce research data Open

Statement A common mistake in Nissen fundoplication is making the wrap too long, which increases postoperative dysphagia; optimal wrap length is approximately 2 centimeters Open

Quotation One of the common mistakes I would make was that I thought I have all this intraabdominal esophageal length, and I would feel the need to wrap all of that. And I think one of the mistakes that people make is they make the wrap too long, uh, and it adds to dysphagia. Open

Statement Experienced surgeons no longer routinely use a 56 French bougie during hiatal closure, as it becomes less necessary with experience and carries perforation risk Open

Statement For patients with weak esophageal peristalsis (amplitude below 20 mmHg) or connective tissue disease, a Toupet (270-degree posterior) fundoplication is preferred over full Nissen to avoid creating pseudoachalasia Open

Statement The best operation to prevent reflux is a Nissen fundoplication, but in patients with poor esophageal motility, the esophageal pump cannot overcome the barrier, necessitating a partial wrap Open

Quotation The best operation we have to prevent reflux is a Nissent fundoplication, and while it's a very good operation to let the acid not go back up, the pump of your esophagus doesn't work good enough to make it past that barrier. Open

Statement Toupet fundoplication is made slightly longer than Nissen (2.5 to almost 3 centimeters) with three sutures on either side, esophagus to stomach Open

Statement A patient with no dysphagia two weeks after Nissen fundoplication is concerning because it indicates the wrap was made too loose and will likely fail long-term Open

Statement Anti-reflux surgery changes swallowing mechanics, stomach function, and acid movement; patients must understand these changes are permanent Open

Quotation The person I worry about the most is the person who shows up two weeks after an innocent and says they've been eating everything they want and they don't have any dysphagia because you know you made it too loose and you're in trouble. Open

Quotation This operation changes things. It's going to change the way you swallow. It's going to change the way your stomach works, and it's going to change the way acid moves throughout your body. Open

Quotation The hardest transition of becoming and attending 12 years ago and doing 4 gut surgery was managing patient satisfaction after this operation and realizing when you don't go off service and you don't leave after you do 20 Nissans that people come back with complaints. Open

Statement Endoscopic intervention for postoperative dysphagia should not be considered until three months postoperatively, even if the patient can only tolerate liquids, as long as there is no anatomic problem Open

Statement Fundoplication wraps are tightest immediately after surgery and loosen over time; early dysphagia is expected and normal Open

Statement Pseudoachalasia after fundoplication presents with dilated esophagus, bird's beak appearance, and manometry showing absent peristalsis with non-relaxing LES, likely due to wrap being too tight causing esophageal burnout Open

Statement Treatment options for pseudoachalasia include taking down the Nissen, performing Heller myotomy with Dor fundoplication, or converting to Toupet wrap with long Heller myotomy Open

Statement For reoperative foregut surgery, the best approach is to plan to completely take down the wrap and start over, though this may not always be necessary or possible Open

Quotation I think for complex reoperative for gut surgery. You have to start over because dysphagia, was it twisted a little bit? All those things get hard to sort out. Open

Statement For morbidly obese patients (BMI over 35) with GERD, gastric bypass is preferred over Nissen fundoplication as the primary operation because Nissen does not work well in this population Open

Statement Nausea and vomiting as prominent symptoms in GERD patients are red flags suggesting delayed gastric emptying; these patients require careful evaluation before proceeding with fundoplication Open

Quotation Nausea and vomiting are red flags to me. Be careful going even in the primary situation if nausea and vomiting is a large component. Open

Statement Before reoperative anti-reflux surgery, complete re-evaluation is essential including 48-hour Bravo study for symptom correlation, repeat manometry, and gastric emptying study Open

Statement The first goal in reoperative fundoplication is to identify the right crus at its base, which provides orientation and prevents drifting into the inferior vena cava Open

Statement Reoperative foregut surgery requires identifying named structures and systematic dissection rather than creating spaces, or the surgeon will quickly become lost Open

Statement Most primary fundoplications fail to create adequate scar tissue in the chest; if struggling with reoperative dissection below, the second approach is to enter the chest wherever possible and work back down Open

Statement Sharp dissection is preferred over harmonic scalpel when taking liver off the wrap in reoperative surgery, accepting some bleeding that can be compressed with the retractor paddle Open

Quotation The key, and where I've seen young people get in trouble, and what I've been in trouble myself in this is where you try to make a space and not do a dissection. So this has to be identifying name structures, digging them out in a very systematic fashion, and not being erratic or you get lost quick. Open

Statement In reoperative foregut surgery, prior port placement reveals the extent of original dissection: umbilical incision indicates no chest dissection was performed; five ports with lowest 5 cm from umbilicus indicates extensive original dissection Open

Statement For delayed gastric emptying after vagal injury, early Botox injection to the pylorus is preferred over pyloroplasty unless both vagal nerves were clearly transected Open

Statement If anterior vagus nerve is injured during reoperative fundoplication but posterior vagus is intact, observation is appropriate; postoperative upper GI on day 1-2 assesses gastric emptying Open

Gastroesophageal Reflux Disease

Statement For initial GERD management in a patient never on PPIs, start with 20mg daily Prilosec for 6 weeks Open

Statement PPIs are preferred over H2 blockers because they don't need to be taken as often, last longer, and are more convenient as once-daily drugs Open

Statement There is mounting data that lifetime use of proton pump inhibitors has consequences associated with it Open

Statement At minimum, patients with GERD symptoms requiring continued PPI therapy need upper endoscopy to assess esophagitis and rule out Barrett's esophagus Open

Statement In 2016, for a patient without esophagitis, no hiatal hernia, and no Barrett's, more workup is needed before keeping them on PPIs indefinitely, especially in young active people due to concerns about osteoporosis and other issues Open

Statement A Bravo pH study is preferred over traditional pH monitoring because it's easier for the patient (no nasal tube) Open

Statement Bravo pH testing should be done off PPIs to allow for symptom correlation, which is important for setting patient expectations about what surgery will improve Open

Statement Manometry is not needed at initial workup but is essential before any surgical discussion Open

Statement The primary reason for manometry before fundoplication is to rule out achalasia, because wrapping someone with achalasia destroys their esophageal function Open

Quotation If you wrap somebody with ankylasia, you have really destroyed their esophageal function. Open

Statement On manometry, look for total relaxation of the lower esophageal sphincter with swallowing and a low resting LES pressure to support the diagnosis of reflux disease Open

Statement Distal esophageal amplitudes on manometry help tailor the fundoplication type, with detailed discussion needed about postoperative dysphagia expectations in patients with poor esophageal motility, and consideration of the difference between full wrap and Toupet Open

Statement For laparoscopic Nissen fundoplication, a full mediastinal dissection is important to create scar tissue and reduce recurrences, and also provides more esophageal length Open

Statement Taking down the short gastric vessels during Nissen makes it easier to avoid twisting the wrap and to see exactly what is being brought around Open

Statement It's important to bring the posterior aspect of the stomach to the anterior aspect so there's a ridge of short gastrics behind the GE junction Open

Statement The way a Nissen is created is highly variable, and one downside of this operation that makes it hard to reproduce data is that everybody does it just a little bit differently without great standardization Open

Statement A common mistake when younger was making the wrap too long because of having good intraabdominal esophageal length; this adds to dysphagia Open

Statement For Nissen fundoplication, use 3 sutures with silk, making the wrap about 2 centimeters long (nothing longer); first stitch is stomach to stomach to allow positioning adjustment, then stomach-esophagus-stomach just above GE junction, then another above that Open

Statement The last stitch is a posterior gastropexy taking the posterior aspect of the stomach to the crus; doing this beforehand is 'cheating' because the stomach should sit there without tension Open

Quotation I don't like to do it, which I know you do it, uh, beforehand, uh, because I, I think that's a little bit cheating that the stomach should be sitting there without tension. Open

Statement Earlier in career, a 56 French bougie was used for crural closure, but with more experience it's needed less and less; now close the crus without a bougie Open

Statement The crus should be closed enough so the esophagus has a little V-shaped triangle of air below it; as experience increases, the crural closure is made tighter Open

Statement In patients with connective tissue disease and weak peristalsis (below 20 mmHg) with very weak LES, the key is to have a clear discussion that the goal is to improve reflux without creating dysphagia, because the esophageal pump doesn't work well enough to overcome a full wrap Open

Statement For patients with weak motility, a Toupet fundoplication (posterior 270-degree wrap) is performed in the vast majority of cases Open

Statement For Toupet fundoplication, perform formal esophageal dissection with Penrose drain, go up into chest, mobilize for intraabdominal esophagus length, take down short gastrics, create posterior 270-degree wrap about 2.5 to almost 3 cm long with 3 sutures on either side (esophagus to stomach), then do posterior gastropexy of stomach to posterior crus Open

Statement For Toupet, only one stitch is used for posterior gastropexy to the crus (not to each side) to avoid angulating things awkwardly and pulling the stomach Open

Statement The hardest transition of becoming an attending 12 years ago doing foregut surgery was managing patient satisfaction after fundoplication and realizing patients come back with complaints and issues, and learning when to intervene Open

Quotation I would say the hardest transition of becoming and attending 12 years ago and doing for gut surgery. Was managing patient satisfaction after this operation and realizing when you don't go off service and you don't leave after you do 20 Nissans that people come back with complaints. Open

Quotation This operation changes things. It's going to change the way you swallow. It's going to change the way your stomach works, and it's going to change the way acid moves from out your body. Open

Statement It's critical to tell patients preoperatively that fundoplication changes things: it will change how you swallow, how your stomach works, and how acid moves out of your body Open

Statement Fundoplication is tightest right after surgery and gets looser over time Open

Quotation The person I worry about the most is the person who shows up two weeks after innocent and says they've been eating everything they want and they don't have any dysphagia because you know you made it too loose and you're in trouble, uh, long term. Open

Statement The expectation is that patients will have dysphagia postoperatively; the patient to worry about most is one who shows up two weeks after Nissen eating everything without dysphagia, because the wrap was made too loose and there will be trouble long-term Open

Statement Would not worry about early postoperative dysphagia whatsoever for the first 6 weeks, even if the patient had to maintain a liquid diet Open

Statement Would not consider endoscopic intervention for dysphagia until 3 months postoperatively with no progression and no ability to tolerate anything besides liquids Open

Statement For persistent dysphagia at 6-8 months, first get an upper GI to make sure the hernia hasn't recurred, ensure there's no anatomic reason, and look at where the hang-up is Open

Statement If there's no recurrence and persistent dysphagia, the assumption is the wrap was calibrated too tight, and the next move would be endoscopy with expectation for dilation Open

Statement If a patient one year post-fundoplication has dilated esophagus with bird's beak appearance on upper GI, tight GE junction on EGD with retained fluid pool, and manometry shows lack of peristalsis with non-relaxing LES, this represents pseudoachalasia where the esophagus has burned out from being too tight too long and can no longer pump food through Open

Quotation You have to have a conversation with the patient that, you know, likely due to the wrap potentially just being too tight and this long of dysphagia, the esophagus is burned out and it's no longer able to pump the food through. Open

Statement For pseudoachalasia, before rushing to the operating room, ensure nutrition is optimized; if not, consider PEG tube for feeding beforehand Open

Statement For pseudoachalasia with optimized nutrition, the approach would most likely be to take down the Nissen, do a Heller myotomy, and probably add a Dor fundoplication Open

Statement For complex reoperative foregut surgery, the best approach is to plan to go in and start over again, though if unable to take the wrap down completely, can fall back on dividing it and leaving it as half a wrap Open

Quotation I think for complex reoperative foregut surgery. You have to start over because dysphagia, was it twisted a little bit? All those things get hard to sort out. Open

Statement For morbidly obese patients with BMI over 35 and reflux, refer to bariatric surgery for gastric bypass rather than fundoplication Open

Statement For symptomatic herniated wrap, reevaluate from the start with 48-hour Bravo study to understand symptom correlation and have honest discussion about what can be improved Open

Statement For reoperative patients, especially if the first surgery wasn't done by you, want to know gastric emptying function because delayed gastric emptying symptoms overlap with reflux and might have led to some problems Open

Statement Nausea and vomiting are red flags to be careful, even in primary fundoplication; if these are large components of complaints, put the brakes on rushing to surgery and really understand what's going on Open

Statement For reoperative slipped Nissen, the first step is looking at where prior surgeon put incisions: if there's an incision in the belly button, they never went up in the chest; if all 5 incisions with lowest 5cm from umbilicus, they did a real operation Open

Statement The first goal of reoperative fundoplication is to get to the right crus, which is the most important part because then you know where the cava is and where you can get in big trouble Open

Statement In reoperative surgery, where the liver and wrap are obliterating the right crus, drifting off the wrap can lead to injury of the cava Open

Statement First get the liver off the wrap using hook or scissors and accept bleeding, because the plan is to put the paddle (12mm retractor) there to compress any bleeding; using harmonic can injure the wrap which may be needed later Open

Statement Want to go specifically for the right crus at the base; most people haven't taken dissection low enough to the base of the crus Open

Statement A lot of fundoplications come back because there's just not scar tissue in the chest; if struggling down low, the second move is to get up in the chest wherever possible and work back down Open

Statement The key in reoperative surgery is identifying named structures and digging them out in a systematic fashion, not trying to make a space without doing a dissection, or you get lost quickly Open

Quotation The key, and where I've seen young people get in trouble, and what I've been in trouble myself in this is where you try to make a space and not do a dissection. Open

Statement If the anterior vagus nerve is injured during reoperative fundoplication but the posterior vagus is OK, would do nothing acutely in the operating room Open

Statement For reoperative surgery, get upper GI on first or second postoperative day to look at gastric emptying as a poor man's gastric emptying study Open

Statement If concerned about vagal injuries postoperatively with poor gastric emptying, would go early to Botox of the pylorus rather than doing pyloroplasty at the time of operation unless convinced both vagus nerves were taken Open

Michael's statements about Inguinal Hernia 178 statements

Open the Inguinal Hernia collection →

Inguinal Hernia: Adult

Quotation I have to say that can be one of the hardest things to do because there are small hernias that on physical exam are extremely difficult to feel. Open

Quotation Just remember that anytime somebody stands up and coughs or does a Valsalva, there's always the cord structures that are gonna be giving you an impulse, so you really wanna make sure that you actually see a bulge, and it's a true hernia. Open

Statement 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. Open

Statement In the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years. Open

Statement 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. Open

Statement 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. Open

Statement 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. Open

Quotation The odds are in a couple of years, they might not have any symptoms and you'll be OK, but in a younger patient, the odds are against them that they're going to live the rest of their life without this becoming symptomatic. Open

Statement Inguinal hernia repairs can be performed under local anesthesia in high-risk patients. Open

Statement 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. Open

Statement Inguinal hernia repairs can be performed under local anesthesia in high-risk patients. Open

Quotation It's much worse for them to present with an emergency problem in the middle of the night, which could be life threatening. Open

Statement For unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support. Open

Statement The best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature. Open

Statement 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. Open

Statement The learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required. Open

Statement 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. Open

Statement 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. Open

Statement TAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes. Open

Statement 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. Open

Statement 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. Open

Statement 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. Open

Quotation I think that that surgical skill is critical, and you don't want to be getting an inguinal hernia in the patient's first in the surgeon's first couple laparoscopic inguinal hernia operates because there is a real learning curve. Open

Quotation The laparoscopic repair offers you about 1 week to 10 days earlier recovery. It's not a month, it's not 3 or 4 months, but it is about 1 week to 10 days in my practice. Open

Statement Laparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair. Open

Quotation The laparoscopic repair offers you about 1 week to 10 days earlier recovery. It's not a month, it's not 3 or 4 months, but it is about 1 week to 10 days in my practice. Open

Statement Laparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair. Open

Statement 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. Open

Quotation The consequence of chronic pain, which is starting to become one of the most common things that I see in my clinic with open mesh repairs, it is not worth that risk in a young, healthy, active patient. Open

Statement 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. Open

Statement 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. Open

Statement 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. Open

Statement The benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile. Open

Statement 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. Open

Statement 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. Open

Statement Previous prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs. Open

Statement 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. Open

Statement Parietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs. Open

Statement 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. Open

Statement 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. Open

Quotation The inferior dissection is the Achilles heel any laparoscopic repair because it's awkward to view it. It's a little bit scary you're gonna start to make holes in it and you're taking it very close off the vessels. Open

Statement When surgeons do not take the peritoneum far enough back inferiorly, they tend to use a smaller piece of mesh, which is problematic. Open

Statement All mesh contracts to some degree and can move. Open

Quotation If you go back and read Stopa's original descriptions, his description, if you were doing a unilateral inguinal hernia was to never use less than a 15 by 15 centimeter piece of mesh or a 6 by 6 inch piece of mesh, which is much bigger than the vast majority of laparoscopic pre-formed meshes or or meshes that are being placed. Open

Statement 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. Open

Statement For large direct inguinal hernias, mesh choice should change and surgeons should use a heavier weight material. Open

Statement Mesh weight categories (heavyweight, midweight, lightweight) were defined by marketing companies, not based on science. Open

Statement Heavyweight mesh is approximately 90 grams per meter squared (e.g., Marlex or Prolene). Open

Statement Lightweight mesh (Ultrapro) is less than 30 grams per meter squared, starting heavier but degrading over time to about 28 grams per meter squared. Open

Statement Midweight mesh is between 40 to 50 grams per meter squared. Open

Statement Advantages of lighter weight mesh include less foreign body, less palpability, and potentially less contraction because it ingrows more. Open

Statement 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. Open

Statement Heavier weight mesh rarely breaks, but patients sometimes feel it in their groin if there are wrinkles or buckles, which can cause issues. Open

Statement 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. Open

Statement 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. Open

Quotation If you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space to put the mesh. Open

Statement If the mesh is too big during laparoscopic inguinal hernia repair, the problem is not the mesh size but inadequate dissection of the space. Open

Statement Dr. Rosen believes mesh should be fixed in laparoscopic inguinal hernia repair and uses ProTack, though some surgeons use glue or no fixation. Open

Statement Even surgeons who advocate no fixation will selectively use fixation for large direct hernias. Open

Statement There is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to non-absorbable fixation. Open

Quotation If you put it through the nerve, it's the neuroma that causes the problem, not the attack. Open

Statement If a tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself. Open

Statement Dr. Rosen performs Lichtenstein repair as his preferred open inguinal hernia technique. Open

Statement There is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field, with several series in ventral hernias supporting this. Open

Statement Depending on the level of contamination and indication, it is also appropriate to perform a Bassini or McVay repair without mesh in contaminated fields. Open

Statement 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. Open

Statement 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. Open

Statement 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. Open

Statement 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. Open

Statement 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. Open

Statement For known bilateral inguinal hernias in a skilled laparoscopic surgeon's hands, laparoscopy is the preferred approach. Open

Statement 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. Open

Statement For large inguinoscrotal hernias, Dr. Rosen now performs all repairs open, whereas when he was younger he did them laparoscopically. Open

Statement 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. Open

Statement For truly incarcerated hernias, TEP repair is not a good idea because surgeons want the hernia contents out of the sac; TAPP is preferred. Open

Statement Surgeons can laparoscopically cut the internal ring at the 2 o'clock position while watching the epigastric vessels to help reduce an incarcerated hernia. Open

Statement 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. Open

Inguinal Hernia With M. Rosen

Quotation I think like anybody who sent you with an inguinal hernia, first you want to do an exam and you want to confirm whether they have an inguinal hernia. I have to say that can be one of the hardest things to do because there are small hernias that on physical exam are extremely difficult to feel. Open

Statement In Fitzgibbons' VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem requiring operation due to incarceration or strangulation was less than 1% (actually one-third of 1%). Open

Statement In Fitzgibbons' original two-year VA study, almost one-third of patients in the observation group went on to develop symptoms and need an operation. Open

Quotation So it's safe to watch people. But the problem with this study is this study was over two years. Almost a third of the patients went on to develop symptoms and need an operation. Open

Statement In long-term follow-up of Fitzgibbons' VA study patients (approximately five years), almost three-quarters of patients developed symptoms requiring repair. Open

Quotation I think that the right answer to that question would be defined based on the patient that you have in front of you. And I think equally, if not more important, based on your skill set and where you're at with the learning curve of all of these operations. Open

Quotation And it's been shown in the literature that the best approach is what you do best. Open

Statement The learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200 to 250 cases required. Open

Statement In laparoscopic inguinal hernia repair, mesh is placed away from the nerves, and the risk of chronic pain when done correctly is lower than in open inguinal hernias. Open

Statement Laparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair, not a month or three to four months. Open

Quotation I think the disadvantage of it is that you have to operate near the intestines, whereas open, you're in a separate plane. So there is a risk of intestinal injury. There's a risk of injury to the major blood vessels because you're in that area. But again, if you are safe and know those planes, that risk should be incredibly low. Open

Quotation You have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias. Because if you're pushing it laparoscopically in a sick, comorbid patient, more often than not, it's because you don't feel comfortable doing it the opening of the way and you use your go-to move. Open

Statement The most important part of any laparoscopic repair is parietalization of the cord (stripping the peritoneum off the cord inferiorly and posteriorly), a principle promoted by Rene Stoppa during open preperitoneal repairs. Open

Quotation I think the most important part of any laparoscopic repair, and it's a basic principle that Rene Stoppa promoted during open preperitoneal repairs, which is parietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly. Open

Statement The risk of recurrence in laparoscopic repair is the peritoneum coming under the mesh and then going back out to the defect inferiorly. Open

Quotation And the inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view it. It's a little bit scary that you're going to start to make holes in it, and you're taking it very close off the vessels. Open

Statement According to Stoppa's original descriptions, for a unilateral inguinal hernia repair, one should never use less than a 15 by 15 centimeter piece of mesh (or 6 by 6 inch), which is much bigger than the vast majority of laparoscopic preformed meshes being placed. Open

Statement Heavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene mesh), midweight mesh is 40-50 grams per meter squared, and lightweight mesh (Ultrapro) is less than 30 grams per meter squared. Open

Statement The advantage of lighter weight mesh is less foreign body and potentially less contraction due to better ingrowth; the disadvantage is half the material, which in direct hernias where muscles never come back together puts the mesh at risk for fracturing. Open

Quotation If you're doing an inguinal hernia, I don't think you should ever use smaller than a large of those preformed meshes because you need to cover the whole myelope. Open

Quotation If you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh. And it's not because you have too big of a mesh. It's because you need to take out the mesh and dissect bigger. Open

Statement There is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes compared to permanent fixation. Open

Statement If absorbable fixation is put through a nerve, it is the neuroma that causes the problem, not the tack itself. Open

Statement There is mounting evidence that medium-weight polypropylene mesh can be placed in a contaminated field, with several series demonstrating this in ventral hernias. Open

Statement For incarcerated femoral hernias, the lacunar ligament can be released medially to gain an extra centimeter of space for reduction without destroying the inguinal floor or inguinal ligament. Open

Statement For recurrent hernias, the surgeon should go where nobody has been before; if somebody has been in both places, go where you are best. Open

Statement For bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach. Open

Statement Surgeons learning laparoscopic inguinal hernia repair should avoid bilateral and recurrent hernias during their learning curve, although these patients might benefit most, they have the highest risk. Open

Michael's statements about Low Cardiac Output 150 statements

Open the Low Cardiac Output collection →