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.
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.
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.
I think you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But 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.
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.
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.
quoteI 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.↗
▶Ep 1 · 3:22
epidemiologicalIn 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%).↗
▶Ep 1 · 4:00
epidemiologicalIn Fitzgibbons' original two-year VA study, almost one-third of patients in the observation group went on to develop symptoms and need an operation.↗
▶Ep 1 · 4:00
quoteSo 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.↗
▶Ep 1 · 4:20
epidemiologicalIn long-term follow-up of Fitzgibbons' VA study patients (approximately five years), almost three-quarters of patients developed symptoms requiring repair.↗
▶Ep 1 · 8:20
quoteI 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.↗
▶Ep 1 · 8:30
quoteAnd it's been shown in the literature that the best approach is what you do best.↗
▶Ep 1 · 8:40
clinicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200 to 250 cases required.↗
▶Ep 1 · 9:20
clinicalIn 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.↗
▶Ep 1 · 12:10
clinicalLaparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair, not a month or three to four months.↗
▶Ep 1 · 12:30
quoteI 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.↗
▶Ep 1 · 15:50
quoteYou 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.↗
▶Ep 1 · 18:20
clinicalThe 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.↗
▶Ep 1 · 18:20
quoteI 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.↗
▶Ep 1 · 18:40
clinicalThe risk of recurrence in laparoscopic repair is the peritoneum coming under the mesh and then going back out to the defect inferiorly.↗
▶Ep 1 · 18:54
quoteAnd 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.↗
▶Ep 1 · 20:00
clinicalAccording 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.↗
▶Ep 1 · 21:20
clinicalHeavyweight 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.↗
▶Ep 1 · 22:00
clinicalThe 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.↗
▶Ep 1 · 23:00
quoteIf 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.↗
▶Ep 1 · 23:20
quoteIf 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.↗
▶Ep 1 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes compared to permanent fixation.↗
▶Ep 1 · 24:20
clinicalIf absorbable fixation is put through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 1 · 24:56
clinicalThere is mounting evidence that medium-weight polypropylene mesh can be placed in a contaminated field, with several series demonstrating this in ventral hernias.↗
▶Ep 1 · 27:00
clinicalFor 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.↗
▶Ep 1 · 28:12
opinionFor recurrent hernias, the surgeon should go where nobody has been before; if somebody has been in both places, go where you are best.↗
▶Ep 1 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach.↗
▶Ep 1 · 28:40
opinionSurgeons 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.↗
Inguinal Hernia With M. Rosen
▶Ep 2 · 3:22
host_summaryIn the Fitzgibbons VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration/strangulation) requiring operation was less than 1% (actually one-third of 1%) over the initial study period.↗
▶Ep 2 · 4:00
host_summaryIn the Fitzgibbons study, almost one-third of observed patients developed symptoms requiring operation within two years, and by five years almost three-quarters developed symptoms.↗
▶Ep 2 · 4:20
host_summaryPatients who developed symptoms during observation in the Fitzgibbons study did not do any worse with their eventual operation compared to immediate repair.↗
▶Ep 2 · 4:40
opinionFor an 89-year-old with asymptomatic hernia, observation is appropriate because odds are in a couple years they might not develop symptoms, but in younger patients the odds are against them living the rest of their life without symptoms.↗
▶Ep 2 · 6:32
clinicalInguinal hernias can be repaired under local anesthesia in high-risk patients with severe comorbidities (cardiac disease, ascites, coagulopathy).↗
▶Ep 2 · 8:20
quoteI 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.↗
▶Ep 2 · 8:40
quoteI think that ultimately, it's been shown in the literature that the best approach is what you do best.↗
▶Ep 2 · 9:00
host_summaryThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 2 · 9:20
clinicalThe primary advantage of laparoscopic repair is placing mesh away from nerves, resulting in lower risk of chronic pain compared to open repair when done correctly.↗
▶Ep 2 · 9:20
quoteWith the primary reason that there is one difference in skilled surgeons' hands that seems to be consistent, is that laparoscopy, you're putting the mesh away from the nerves, and the risk of chronic pain in laparoscopic inguinal hernia repair, when done right, is lower than the risk in open inguinal hernias.↗
▶Ep 2 · 9:50
epidemiologicalChronic pain incidence in open inguinal hernia repair varies depending on measurement method: very high if detailed surveys are used, lower if only counting patients who present with complaints.↗
▶Ep 2 · 12:10
clinicalLaparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair.↗
▶Ep 2 · 12:25
clinicalThe disadvantage of laparoscopic repair is operating near intestines with risk of intestinal injury and major blood vessel injury, though this risk should be incredibly low with proper technique.↗
▶Ep 2 · 13:20
opinionIn elderly patients or those on anticoagulation requiring quick restart, open repair is preferred to avoid dissecting the retroperitoneal space.↗
▶Ep 2 · 14:26
opinionIn a 78-year-old with symptomatic hernia on one side and asymptomatic hernia discovered laparoscopically on the other side, repairing the asymptomatic side doubles anesthetic time and increases hematoma risk without clear benefit.↗
▶Ep 2 · 15:50
quoteI think you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But 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.↗
▶Ep 2 · 16:26
opinionPrevious lower abdominal surgery increases risk of enterotomy and OR time for laparoscopic repair; if patient has not had previous open inguinal hernia, open approach is preferred.↗
▶Ep 2 · 16:55
opinionPrevious prostate surgery creates unpredictable difficulty for laparoscopic repair, ranging from straightforward to brutal; currently managed with open repair.↗
▶Ep 2 · 17:58
clinicalThe most important part of laparoscopic repair is parietalization of the cord (stripping peritoneum off cord inferiorly and posteriorly), a principle promoted by Rene Stoppa in open preperitoneal repairs.↗
▶Ep 2 · 18:10
quoteI 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.↗
▶Ep 2 · 18:40
quoteAnd 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.↗
▶Ep 2 · 18:40
clinicalThe inferior dissection is the Achilles heel of laparoscopic repair because it is awkward to view, risky for creating peritoneal holes, and close to vessels.↗
▶Ep 2 · 19:05
host_summaryInadequate inferior peritoneal dissection leads to use of smaller mesh, but Stoppa's original description for unilateral inguinal hernia specified never using less than 15×15 cm (6×6 inch) mesh, which is larger than most laparoscopic meshes being placed.↗
▶Ep 2 · 19:30
quoteIf 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 preform meshes or meshes that are being placed.↗
▶Ep 2 · 20:30
opinionFor large direct hernias, heavier weight mesh material should be used.↗
▶Ep 2 · 21:02
clinicalHeavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, and lightweight (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 2 · 21:50
clinicalLightweight mesh has less foreign body and may contract less due to better ingrowth, but has half the material and is at risk for fracturing, particularly in direct hernias where it bridges and muscles never come together.↗
▶Ep 2 · 22:30
clinicalHeavier weight mesh rarely breaks but can cause chronic pain if wrinkles or buckles are present in the groin.↗
▶Ep 2 · 23:00
opinionSurgeons commonly downsize preformed meshes; for inguinal hernia repair, never use smaller than a large preformed mesh to cover the entire myopectineal orifice.↗
▶Ep 2 · 23:24
clinicalIf struggling with mesh placement during laparoscopic repair, the problem is inadequate dissection of the space, not oversized mesh; the solution is to remove mesh and dissect more widely.↗
▶Ep 2 · 23:24
quoteAnd so 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.↗
▶Ep 2 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to permanent fixation.↗
▶Ep 2 · 24:20
clinicalIf absorbable tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 2 · 24:56
host_summaryThere is mounting evidence that medium-weight polypropylene mesh can be placed in contaminated fields, with several series in ventral hernias supporting this.↗
▶Ep 2 · 25:10
opinionBassini or McVay tissue repairs remain appropriate operations for contaminated fields.↗
▶Ep 2 · 25:55
clinicalFor incarcerated femoral hernia with bowel compromise, an infrainguinal vertical incision allows direct access to the hernia sac, bowel resection if needed, and reduction without dividing the inguinal ligament.↗
▶Ep 2 · 26:35
clinicalTo facilitate reduction of incarcerated femoral hernia contents, the lacunar ligament (medial to femoral space) can be released with scissors or bovie to gain an extra centimeter, avoiding destruction of the inguinal ligament.↗
▶Ep 2 · 27:20
clinicalReverse McVay repair for femoral hernia involves taking the inferior border of the inguinal ligament and sewing it down to Cooper's ligament from below, starting immediately lateral to the femoral vein to avoid impingement.↗
▶Ep 2 · 27:46
clinicalMesh plugs in femoral hernia repair can cause DVT due to irritation of the femoral vein, particularly in thin women who typically present with femoral hernias.↗
▶Ep 2 · 28:12
opinionFor recurrent hernias, operate where no prior surgery has been performed; if both spaces have been operated, choose the approach where you have the most skill.↗
▶Ep 2 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach, but surgeons learning laparoscopy should avoid bilateral and recurrent hernias as these are twice as hard despite potentially offering the most benefit.↗
▶Ep 2 · 29:09
opinionLarge inguinoscrotal hernias are managed with open operation; if truly incarcerated and cannot be reduced in office, open approach is used.↗
▶Ep 2 · 29:30
clinicalFor difficult-to-reduce but not truly incarcerated hernias, patient can be put to sleep for reduction under anesthesia, then TAPP repair performed; the internal ring can be cut laparoscopically at the two o'clock position (avoiding epigastric vessels) to facilitate reduction.↗
▶Ep 2 · 30:00
clinicalIf bowel holes are made during incarcerated hernia repair, the morbidity of the operation increases unacceptably high.↗
Inguinal Hernia With M. Rosen
▶Ep 3 · 2:10
quoteI 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.↗
▶Ep 3 · 3:22
host_summaryIn the Fitzgibbon 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%).↗
▶Ep 3 · 4:00
quoteSo 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.↗
▶Ep 3 · 4:00
host_summaryIn the Fitzgibbon study over two years, almost one-third of observed patients went on to develop symptoms and need an operation, and by five years almost three-quarters developed symptoms.↗
▶Ep 3 · 4:30
opinionFor an 89-year-old with asymptomatic hernia, observation is appropriate because in a couple years they might not have symptoms, but in younger patients the odds are against them living without it becoming symptomatic.↗
▶Ep 3 · 6:32
clinicalInguinal hernia repairs can be done under local anesthesia in patients with severe comorbidities, and it is worse for them to present with an emergency problem in the middle of the night.↗
▶Ep 3 · 8:20
quoteI 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.↗
▶Ep 3 · 9:00
host_summaryThere is a real learning curve to laparoscopic inguinal hernia repair, with some studies showing 200 to 250 cases required.↗
▶Ep 3 · 9:20
clinicalThe primary advantage of laparoscopy in skilled hands is that mesh is placed away from nerves, and the risk of chronic pain is lower than in open inguinal hernias.↗
▶Ep 3 · 9:40
quoteI think that how do you measure chronic pain in open inguinal hernias depends. If you do a very detailed survey, you'll have a very high incidence of chronic pain. If you just wait until patients come back and present with chronic pain, it will be lower. But those patients are absolutely miserable.↗
▶Ep 3 · 10:44
quoteI think the TEP pair, it's a little bit more expensive because you need to use the balloon. It's a little bit smaller of a space, but perhaps the angles are a little bit easier to operate with. I think a TAP, you get a little bit of a better view. You get a little bit more of a working space.↗
▶Ep 3 · 11:20
quoteThe way that I look at it is it's the same room. One comes through the front door. One comes through the ceiling. Ultimately, you work in the same space, and it should be the same operation regardless.↗
▶Ep 3 · 11:53
opinionFor young, healthy, active patients with unilateral hernia who are not anesthetic risks, laparoscopic repair is preferred in experienced hands, offering about a week to 10 days earlier recovery than open repair.↗
▶Ep 3 · 12:30
clinicalDisadvantages of laparoscopic repair include operating near intestines with risk of intestinal injury and risk of injury to major blood vessels, though these risks should be incredibly low if planes are known.↗
▶Ep 3 · 13:00
opinionIn elderly patients or anyone on anticoagulation who needs to restart quickly, open operation is preferred to avoid dissecting the retroperitoneal space.↗
▶Ep 3 · 14:09
opinionIn a 78-year-old patient with symptomatic hernia on one side and asymptomatic hernia discovered laparoscopically on the other side, the asymptomatic side should not be repaired due to doubled anesthetic time and increased hematoma risk.↗
▶Ep 3 · 14:58
opinionIn younger active patients, an asymptomatic contralateral hernia discovered laparoscopically should be repaired because the chance of it becoming symptomatic is much higher.↗
▶Ep 3 · 15:50
quoteI think that you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But you have to check your minimally invasive ego at the door.↗
▶Ep 3 · 16:26
opinionPrevious lower abdominal surgery increases risk of enterotomy and OR time for laparoscopic repair; if patient hasn't had open inguinal hernia, open approach is preferred.↗
▶Ep 3 · 16:55
opinionPrevious prostate surgery cases are unpredictable laparoscopically and can be brutal; in current practice these get open inguinal hernia repair.↗
▶Ep 3 · 17:58
clinicalThe most important part of any laparoscopic repair is parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly), a principle promoted by Rene Stoppa during open preperitoneal repairs.↗
▶Ep 3 · 18:10
quoteI 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.↗
▶Ep 3 · 18:40
quoteAnd 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.↗
▶Ep 3 · 18:40
clinicalThe inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view, scary to make holes, and taken very close off the vessels.↗
▶Ep 3 · 19:10
host_summaryAccording to Stoppa's original descriptions, for unilateral inguinal hernia repair, 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 meshes being placed.↗
▶Ep 3 · 20:40
opinionFor large direct hernias, mesh choice should change to a heavier weight material.↗
▶Ep 3 · 21:02
clinicalHeavyweight mesh is around 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, and lightweight (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 3 · 21:50
clinicalAdvantage of lighter weight mesh is less foreign body and less contraction; disadvantage is half the material with risk of fracturing, particularly in direct hernias where it's a bridge.↗
▶Ep 3 · 22:30
clinicalHeavier weight mesh rarely breaks but sometimes people feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 3 · 23:00
quoteSo 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.↗
▶Ep 3 · 23:00
opinionFor inguinal hernia repair, should never use smaller than a large preformed mesh because you need to cover the whole myopectineal orifice.↗
▶Ep 3 · 23:24
clinicalIf struggling with mesh placement during laparoscopic repair, it's not that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space enough - you need to take out the mesh and dissect bigger.↗
▶Ep 3 · 23:24
quoteAnd so 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.↗
▶Ep 3 · 23:53
opinionMesh should be fixed in place; options include Protack tacks, glue, or no fixation, though for big direct hernias everybody uses fixation.↗
▶Ep 3 · 24:09
quoteNo evidence that absorbable fixation causes reduction in pain, better fixation, or improve long-term outcomes. So I use permanent fixation. And absorbable fixation, if you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 3 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes; permanent fixation is used because if absorbable fixation goes through a nerve, it's the neuroma that causes the problem, not the tack.↗
▶Ep 3 · 24:56
host_summaryThere is mounting evidence that medium-weight polypropylene can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
▶Ep 3 · 25:55
clinicalFor incarcerated femoral hernia with bowel compromise, make a vertical incision for vascular-type exposure, dissect onto hernia sac, bring out compromised intestine infrainguinally, resect and anastomose, then reduce.↗
▶Ep 3 · 26:32
clinicalTo reduce incarcerated femoral hernia without dividing inguinal ligament, release the lacunar ligament medially (which gives off from the inguinal ligament) to gain an extra centimeter of space.↗
▶Ep 3 · 27:10
clinicalA 'reverse McVay' repair can be performed from below for femoral hernias, taking the inferior border of the inguinal ligament and sewing it down to Cooper's ligament starting immediately lateral to the femoral vein.↗
▶Ep 3 · 27:46
clinicalMesh plugs are not preferred for femoral hernias because femoral hernias tend to occur in thin women and there have been DVTs due to irritation on the femoral vein.↗
▶Ep 3 · 28:12
opinionFor recurrent hernias, operate where nobody has been before; if both spaces have been operated, go where you're best.↗
▶Ep 3 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach, but if learning, avoid bilateral and recurrent hernias laparoscopically because it makes it twice as hard despite these patients getting the most benefit.↗
▶Ep 3 · 29:09
opinionFor really big inguinal scrotal hernias that can't be reduced in office, open operation is preferred; when younger, these were done laparoscopically but now all done open.↗
▶Ep 3 · 29:40
clinicalFor incarcerated hernias, TAP approach is preferred over TEP because you want the contents out of the hernia; can laparoscopically cut the internal ring at the two o'clock position relative to epigastric vessels to help reduce.↗
quoteI 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.↗
▶Ep 6 · 2:17
quoteI 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.↗
▶Ep 6 · 2:38
quoteJust 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.↗
▶Ep 6 · 2:38
quoteJust 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.↗
▶Ep 6 · 3:30
epidemiologicalIn 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.↗
▶Ep 6 · 3:30
epidemiologicalIn 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.↗
▶Ep 6 · 4:11
epidemiologicalIn the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years.↗
▶Ep 6 · 4:11
epidemiologicalIn the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years.↗
▶Ep 6 · 4:21
epidemiologicalIn long-term follow-up of the Fitzgibbons study, almost three-fifths of patients in the observation group developed symptoms requiring operation by 5 years.↗
▶Ep 6 · 4:21
epidemiologicalIn long-term follow-up of the Fitzgibbons study, almost three-fifths of patients in the observation group developed symptoms requiring operation by 5 years.↗
▶Ep 6 · 4:33
opinionFor 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.↗
▶Ep 6 · 4:33
opinionFor 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.↗
▶Ep 6 · 4:36
quoteThe 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.↗
▶Ep 6 · 4:36
quoteThe 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.↗
▶Ep 6 · 4:36
opinionFor 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.↗
▶Ep 6 · 4:36
opinionFor 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.↗
▶Ep 6 · 6:06
clinicalInguinal hernia repairs can be performed under local anesthesia in high-risk patients.↗
▶Ep 6 · 6:06
opinionFor 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.↗
▶Ep 6 · 6:06
opinionFor 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.↗
▶Ep 6 · 6:06
quoteIt's much worse for them to present with an emergency problem in the middle of the night, which could be life threatening.↗
▶Ep 6 · 6:06
clinicalInguinal hernia repairs can be performed under local anesthesia in high-risk patients.↗
▶Ep 6 · 6:06
quoteIt's much worse for them to present with an emergency problem in the middle of the night, which could be life threatening.↗
▶Ep 6 · 7:56
clinicalFor unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support.↗
▶Ep 6 · 7:56
clinicalFor unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support.↗
▶Ep 6 · 8:29
opinionThe best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature.↗
▶Ep 6 · 8:29
opinionThe best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature.↗
▶Ep 6 · 9:04
opinionFor 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.↗
▶Ep 6 · 9:04
epidemiologicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 6 · 9:04
opinionFor 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.↗
▶Ep 6 · 9:04
epidemiologicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 6 · 9:18
clinicalIn 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.↗
▶Ep 6 · 9:18
clinicalIn 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.↗
▶Ep 6 · 9:51
clinicalChronic 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.↗
▶Ep 6 · 9:51
clinicalChronic 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.↗
▶Ep 6 · 10:45
epidemiologicalTAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes.↗
▶Ep 6 · 10:45
epidemiologicalTAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes.↗
▶Ep 6 · 10:58
clinicalTEP repair requires use of a balloon dissector, which is more expensive, and provides a smaller working space but perhaps easier angles to operate with.↗
▶Ep 6 · 10:58
clinicalTEP repair requires use of a balloon dissector, which is more expensive, and provides a smaller working space but perhaps easier angles to operate with.↗
▶Ep 6 · 11:09
clinicalTAPP 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.↗
▶Ep 6 · 11:09
clinicalTAPP 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.↗
▶Ep 6 · 11:26
clinicalTAPP 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.↗
▶Ep 6 · 11:26
clinicalTAPP 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.↗
▶Ep 6 · 12:11
quoteI 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.↗
▶Ep 6 · 12:11
quoteI 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.↗
▶Ep 6 · 12:23
clinicalLaparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair.↗
▶Ep 6 · 12:23
clinicalLaparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair.↗
▶Ep 6 · 12:23
quoteThe 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.↗
▶Ep 6 · 12:23
quoteThe 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.↗
▶Ep 6 · 12:45
clinicalLaparoscopic 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.↗
▶Ep 6 · 12:45
clinicalLaparoscopic 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.↗
▶Ep 6 · 13:06
quoteThe 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.↗
▶Ep 6 · 13:06
quoteThe 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.↗
▶Ep 6 · 13:28
opinionIn 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.↗
▶Ep 6 · 13:28
opinionIn 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.↗
▶Ep 6 · 14:10
opinionIn 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.↗
▶Ep 6 · 14:10
opinionIn 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.↗
▶Ep 6 · 15:17
clinicalPneumoperitoneum 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.↗
▶Ep 6 · 15:17
clinicalPneumoperitoneum 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.↗
▶Ep 6 · 15:39
opinionThe benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile.↗
▶Ep 6 · 15:39
opinionThe benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile.↗
▶Ep 6 · 15:55
opinionSurgeons 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.↗
▶Ep 6 · 15:55
opinionSurgeons 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.↗
▶Ep 6 · 15:55
quoteYou 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.↗
▶Ep 6 · 15:55
quoteYou 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.↗
▶Ep 6 · 16:24
opinionPrevious 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.↗
▶Ep 6 · 16:24
opinionPrevious 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.↗
▶Ep 6 · 16:42
opinionPrevious prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs.↗
▶Ep 6 · 16:42
opinionPrevious prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs.↗
▶Ep 6 · 17:52
clinicalBasic 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.↗
▶Ep 6 · 17:52
clinicalBasic 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.↗
▶Ep 6 · 18:15
clinicalParietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs.↗
▶Ep 6 · 18:15
clinicalParietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs.↗
▶Ep 6 · 18:27
clinicalThe 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.↗
▶Ep 6 · 18:27
clinicalThe 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.↗
▶Ep 6 · 18:53
clinicalThe 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.↗
▶Ep 6 · 18:53
clinicalThe 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.↗
▶Ep 6 · 18:56
quoteThe 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.↗
▶Ep 6 · 18:56
quoteThe 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.↗
▶Ep 6 · 19:03
clinicalWhen surgeons do not take the peritoneum far enough back inferiorly, they tend to use a smaller piece of mesh, which is problematic.↗
▶Ep 6 · 19:03
clinicalWhen surgeons do not take the peritoneum far enough back inferiorly, they tend to use a smaller piece of mesh, which is problematic.↗
▶Ep 6 · 19:30
clinicalAll mesh contracts to some degree and can move.↗
▶Ep 6 · 19:30
clinicalAll mesh contracts to some degree and can move.↗
▶Ep 6 · 19:40
clinicalAccording 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.↗
▶Ep 6 · 19:40
quoteIf 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.↗
▶Ep 6 · 19:40
quoteIf 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.↗
▶Ep 6 · 19:40
clinicalAccording 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.↗
▶Ep 6 · 20:26
opinionFor large direct inguinal hernias, mesh choice should change and surgeons should use a heavier weight material.↗
▶Ep 6 · 20:26
opinionFor large direct inguinal hernias, mesh choice should change and surgeons should use a heavier weight material.↗
▶Ep 6 · 21:37
clinicalMesh weight categories (heavyweight, midweight, lightweight) were defined by marketing companies, not based on science.↗
▶Ep 6 · 21:37
clinicalHeavyweight mesh is approximately 90 grams per meter squared (e.g., Marlex or Prolene).↗
▶Ep 6 · 21:37
clinicalMesh weight categories (heavyweight, midweight, lightweight) were defined by marketing companies, not based on science.↗
▶Ep 6 · 21:37
clinicalHeavyweight mesh is approximately 90 grams per meter squared (e.g., Marlex or Prolene).↗
▶Ep 6 · 21:57
clinicalMidweight mesh is between 40 to 50 grams per meter squared.↗
▶Ep 6 · 21:57
clinicalLightweight mesh (Ultrapro) is less than 30 grams per meter squared, starting heavier but degrading over time to about 28 grams per meter squared.↗
▶Ep 6 · 21:57
clinicalMidweight mesh is between 40 to 50 grams per meter squared.↗
▶Ep 6 · 21:57
clinicalLightweight mesh (Ultrapro) is less than 30 grams per meter squared, starting heavier but degrading over time to about 28 grams per meter squared.↗
▶Ep 6 · 22:16
clinicalAdvantages of lighter weight mesh include less foreign body, less palpability, and potentially less contraction because it ingrows more.↗
▶Ep 6 · 22:16
clinicalAdvantages of lighter weight mesh include less foreign body, less palpability, and potentially less contraction because it ingrows more.↗
▶Ep 6 · 22:23
clinicalDisadvantages 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.↗
▶Ep 6 · 22:23
clinicalDisadvantages 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.↗
▶Ep 6 · 22:42
clinicalHeavier weight mesh rarely breaks, but patients sometimes feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 6 · 22:42
clinicalHeavier weight mesh rarely breaks, but patients sometimes feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 6 · 22:51
clinicalPre-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.↗
▶Ep 6 · 22:51
clinicalPre-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.↗
▶Ep 6 · 23:08
opinionFor laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh because the entire myopectineal orifice needs to be covered.↗
▶Ep 6 · 23:08
opinionFor laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh because the entire myopectineal orifice needs to be covered.↗
▶Ep 6 · 23:24
quoteIf 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.↗
▶Ep 6 · 23:24
clinicalIf the mesh is too big during laparoscopic inguinal hernia repair, the problem is not the mesh size but inadequate dissection of the space.↗
▶Ep 6 · 23:24
clinicalIf the mesh is too big during laparoscopic inguinal hernia repair, the problem is not the mesh size but inadequate dissection of the space.↗
▶Ep 6 · 23:24
quoteIf 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.↗
▶Ep 6 · 23:53
opinionDr. Rosen believes mesh should be fixed in laparoscopic inguinal hernia repair and uses ProTack, though some surgeons use glue or no fixation.↗
▶Ep 6 · 23:53
opinionDr. Rosen believes mesh should be fixed in laparoscopic inguinal hernia repair and uses ProTack, though some surgeons use glue or no fixation.↗
▶Ep 6 · 23:59
clinicalEven surgeons who advocate no fixation will selectively use fixation for large direct hernias.↗
▶Ep 6 · 23:59
clinicalEven surgeons who advocate no fixation will selectively use fixation for large direct hernias.↗
▶Ep 6 · 24:10
epidemiologicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to non-absorbable fixation.↗
▶Ep 6 · 24:10
epidemiologicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to non-absorbable fixation.↗
▶Ep 6 · 24:22
clinicalIf a tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 6 · 24:22
quoteIf you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 6 · 24:22
clinicalIf a tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 6 · 24:22
quoteIf you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 6 · 24:30
opinionDr. Rosen performs Lichtenstein repair as his preferred open inguinal hernia technique.↗
▶Ep 6 · 24:30
opinionDr. Rosen performs Lichtenstein repair as his preferred open inguinal hernia technique.↗
▶Ep 6 · 24:56
epidemiologicalThere is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
▶Ep 6 · 24:56
epidemiologicalThere is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
▶Ep 6 · 25:01
opinionDepending on the level of contamination and indication, it is also appropriate to perform a Bassini or McVay repair without mesh in contaminated fields.↗
▶Ep 6 · 25:01
opinionDepending on the level of contamination and indication, it is also appropriate to perform a Bassini or McVay repair without mesh in contaminated fields.↗
▶Ep 6 · 25:55
opinionFor 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.↗
▶Ep 6 · 25:55
opinionFor 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.↗
▶Ep 6 · 26:36
clinicalTo 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.↗
▶Ep 6 · 26:36
clinicalTo 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.↗
▶Ep 6 · 27:19
opinionDr. 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.↗
▶Ep 6 · 27:19
opinionDr. 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.↗
▶Ep 6 · 27:44
opinionDr. 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.↗
▶Ep 6 · 27:44
opinionDr. 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.↗
▶Ep 6 · 28:12
opinionFor 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.↗
▶Ep 6 · 28:12
opinionFor 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.↗
▶Ep 6 · 28:31
opinionFor known bilateral inguinal hernias in a skilled laparoscopic surgeon's hands, laparoscopy is the preferred approach.↗
▶Ep 6 · 28:31
opinionFor known bilateral inguinal hernias in a skilled laparoscopic surgeon's hands, laparoscopy is the preferred approach.↗
▶Ep 6 · 28:36
opinionSurgeons 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.↗
▶Ep 6 · 28:36
opinionSurgeons 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.↗
▶Ep 6 · 29:10
opinionFor large inguinoscrotal hernias, Dr. Rosen now performs all repairs open, whereas when he was younger he did them laparoscopically.↗
▶Ep 6 · 29:10
opinionFor large inguinoscrotal hernias, Dr. Rosen now performs all repairs open, whereas when he was younger he did them laparoscopically.↗
▶Ep 6 · 29:23
opinionFor 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.↗
▶Ep 6 · 29:23
opinionFor 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.↗
▶Ep 6 · 29:30
opinionFor truly incarcerated hernias, TEP repair is not a good idea because surgeons want the hernia contents out of the sac; TAPP is preferred.↗
▶Ep 6 · 29:30
opinionFor truly incarcerated hernias, TEP repair is not a good idea because surgeons want the hernia contents out of the sac; TAPP is preferred.↗
▶Ep 6 · 29:43
clinicalSurgeons can laparoscopically cut the internal ring at the 2 o'clock position while watching the epigastric vessels to help reduce an incarcerated hernia.↗
▶Ep 6 · 29:43
clinicalSurgeons can laparoscopically cut the internal ring at the 2 o'clock position while watching the epigastric vessels to help reduce an incarcerated hernia.↗
▶Ep 6 · 29:53
opinionIf 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.↗
▶Ep 6 · 29:53
opinionIf 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.↗
Inguinal Hernia With M. Rosen
▶Ep 26 · 2:10
quoteI 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.↗
▶Ep 26 · 2:10
quoteI 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.↗
▶Ep 26 · 3:22
epidemiologicalIn 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%).↗
▶Ep 26 · 3:22
epidemiologicalIn 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%).↗
▶Ep 26 · 4:00
epidemiologicalIn Fitzgibbons' original two-year VA study, almost one-third of patients in the observation group went on to develop symptoms and need an operation.↗
▶Ep 26 · 4:00
quoteSo 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.↗
▶Ep 26 · 4:00
quoteSo 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.↗
▶Ep 26 · 4:00
epidemiologicalIn Fitzgibbons' original two-year VA study, almost one-third of patients in the observation group went on to develop symptoms and need an operation.↗
▶Ep 26 · 4:20
epidemiologicalIn long-term follow-up of Fitzgibbons' VA study patients (approximately five years), almost three-quarters of patients developed symptoms requiring repair.↗
▶Ep 26 · 4:20
epidemiologicalIn long-term follow-up of Fitzgibbons' VA study patients (approximately five years), almost three-quarters of patients developed symptoms requiring repair.↗
▶Ep 26 · 8:20
quoteI 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.↗
▶Ep 26 · 8:20
quoteI 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.↗
▶Ep 26 · 8:30
quoteAnd it's been shown in the literature that the best approach is what you do best.↗
▶Ep 26 · 8:30
quoteAnd it's been shown in the literature that the best approach is what you do best.↗
▶Ep 26 · 8:40
clinicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200 to 250 cases required.↗
▶Ep 26 · 8:40
clinicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200 to 250 cases required.↗
▶Ep 26 · 9:20
clinicalIn 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.↗
▶Ep 26 · 9:20
clinicalIn 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.↗
▶Ep 26 · 12:10
clinicalLaparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair, not a month or three to four months.↗
▶Ep 26 · 12:10
clinicalLaparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair, not a month or three to four months.↗
▶Ep 26 · 12:30
quoteI 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.↗
▶Ep 26 · 12:30
quoteI 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.↗
▶Ep 26 · 15:50
quoteYou 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.↗
▶Ep 26 · 15:50
quoteYou 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.↗
▶Ep 26 · 18:20
clinicalThe 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.↗
▶Ep 26 · 18:20
quoteI 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.↗
▶Ep 26 · 18:20
quoteI 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.↗
▶Ep 26 · 18:20
clinicalThe 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.↗
▶Ep 26 · 18:40
clinicalThe risk of recurrence in laparoscopic repair is the peritoneum coming under the mesh and then going back out to the defect inferiorly.↗
▶Ep 26 · 18:40
clinicalThe risk of recurrence in laparoscopic repair is the peritoneum coming under the mesh and then going back out to the defect inferiorly.↗
▶Ep 26 · 18:54
quoteAnd 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.↗
▶Ep 26 · 18:54
quoteAnd 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.↗
▶Ep 26 · 20:00
clinicalAccording 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.↗
▶Ep 26 · 20:00
clinicalAccording 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.↗
▶Ep 26 · 21:20
clinicalHeavyweight 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.↗
▶Ep 26 · 21:20
clinicalHeavyweight 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.↗
▶Ep 26 · 22:00
clinicalThe 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.↗
▶Ep 26 · 22:00
clinicalThe 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.↗
▶Ep 26 · 23:00
quoteIf 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.↗
▶Ep 26 · 23:00
quoteIf 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.↗
▶Ep 26 · 23:20
quoteIf 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.↗
▶Ep 26 · 23:20
quoteIf 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.↗
▶Ep 26 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes compared to permanent fixation.↗
▶Ep 26 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes compared to permanent fixation.↗
▶Ep 26 · 24:20
clinicalIf absorbable fixation is put through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 26 · 24:20
clinicalIf absorbable fixation is put through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 26 · 24:56
clinicalThere is mounting evidence that medium-weight polypropylene mesh can be placed in a contaminated field, with several series demonstrating this in ventral hernias.↗
▶Ep 26 · 24:56
clinicalThere is mounting evidence that medium-weight polypropylene mesh can be placed in a contaminated field, with several series demonstrating this in ventral hernias.↗
▶Ep 26 · 27:00
clinicalFor 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.↗
▶Ep 26 · 27:00
clinicalFor 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.↗
▶Ep 26 · 28:12
opinionFor recurrent hernias, the surgeon should go where nobody has been before; if somebody has been in both places, go where you are best.↗
▶Ep 26 · 28:12
opinionFor recurrent hernias, the surgeon should go where nobody has been before; if somebody has been in both places, go where you are best.↗
▶Ep 26 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach.↗
▶Ep 26 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach.↗
▶Ep 26 · 28:40
opinionSurgeons 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.↗
▶Ep 26 · 28:40
opinionSurgeons 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.↗
Inguinal Hernia With M. Rosen
▶Ep 27 · 3:22
host_summaryIn the Fitzgibbons VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration/strangulation) requiring operation was less than 1% (actually one-third of 1%) over the initial study period.↗
▶Ep 27 · 4:00
host_summaryIn the Fitzgibbons study, almost one-third of observed patients developed symptoms requiring operation within two years, and by five years almost three-quarters developed symptoms.↗
▶Ep 27 · 4:20
host_summaryPatients who developed symptoms during observation in the Fitzgibbons study did not do any worse with their eventual operation compared to immediate repair.↗
▶Ep 27 · 4:40
opinionFor an 89-year-old with asymptomatic hernia, observation is appropriate because odds are in a couple years they might not develop symptoms, but in younger patients the odds are against them living the rest of their life without symptoms.↗
▶Ep 27 · 6:32
clinicalInguinal hernias can be repaired under local anesthesia in high-risk patients with severe comorbidities (cardiac disease, ascites, coagulopathy).↗
▶Ep 27 · 8:20
quoteI 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.↗
▶Ep 27 · 8:40
quoteI think that ultimately, it's been shown in the literature that the best approach is what you do best.↗
▶Ep 27 · 9:00
host_summaryThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 27 · 9:20
clinicalThe primary advantage of laparoscopic repair is placing mesh away from nerves, resulting in lower risk of chronic pain compared to open repair when done correctly.↗
▶Ep 27 · 9:20
quoteWith the primary reason that there is one difference in skilled surgeons' hands that seems to be consistent, is that laparoscopy, you're putting the mesh away from the nerves, and the risk of chronic pain in laparoscopic inguinal hernia repair, when done right, is lower than the risk in open inguinal hernias.↗
▶Ep 27 · 9:50
epidemiologicalChronic pain incidence in open inguinal hernia repair varies depending on measurement method: very high if detailed surveys are used, lower if only counting patients who present with complaints.↗
▶Ep 27 · 12:10
clinicalLaparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair.↗
▶Ep 27 · 12:25
clinicalThe disadvantage of laparoscopic repair is operating near intestines with risk of intestinal injury and major blood vessel injury, though this risk should be incredibly low with proper technique.↗
▶Ep 27 · 13:20
opinionIn elderly patients or those on anticoagulation requiring quick restart, open repair is preferred to avoid dissecting the retroperitoneal space.↗
▶Ep 27 · 14:26
opinionIn a 78-year-old with symptomatic hernia on one side and asymptomatic hernia discovered laparoscopically on the other side, repairing the asymptomatic side doubles anesthetic time and increases hematoma risk without clear benefit.↗
▶Ep 27 · 15:50
quoteI think you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But 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.↗
▶Ep 27 · 16:26
opinionPrevious lower abdominal surgery increases risk of enterotomy and OR time for laparoscopic repair; if patient has not had previous open inguinal hernia, open approach is preferred.↗
▶Ep 27 · 16:55
opinionPrevious prostate surgery creates unpredictable difficulty for laparoscopic repair, ranging from straightforward to brutal; currently managed with open repair.↗
▶Ep 27 · 17:58
clinicalThe most important part of laparoscopic repair is parietalization of the cord (stripping peritoneum off cord inferiorly and posteriorly), a principle promoted by Rene Stoppa in open preperitoneal repairs.↗
▶Ep 27 · 18:10
quoteI 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.↗
▶Ep 27 · 18:40
quoteAnd 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.↗
▶Ep 27 · 18:40
clinicalThe inferior dissection is the Achilles heel of laparoscopic repair because it is awkward to view, risky for creating peritoneal holes, and close to vessels.↗
▶Ep 27 · 19:05
host_summaryInadequate inferior peritoneal dissection leads to use of smaller mesh, but Stoppa's original description for unilateral inguinal hernia specified never using less than 15×15 cm (6×6 inch) mesh, which is larger than most laparoscopic meshes being placed.↗
▶Ep 27 · 19:30
quoteIf 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 preform meshes or meshes that are being placed.↗
▶Ep 27 · 20:30
opinionFor large direct hernias, heavier weight mesh material should be used.↗
▶Ep 27 · 21:02
clinicalHeavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, and lightweight (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 27 · 21:50
clinicalLightweight mesh has less foreign body and may contract less due to better ingrowth, but has half the material and is at risk for fracturing, particularly in direct hernias where it bridges and muscles never come together.↗
▶Ep 27 · 22:30
clinicalHeavier weight mesh rarely breaks but can cause chronic pain if wrinkles or buckles are present in the groin.↗
▶Ep 27 · 23:00
opinionSurgeons commonly downsize preformed meshes; for inguinal hernia repair, never use smaller than a large preformed mesh to cover the entire myopectineal orifice.↗
▶Ep 27 · 23:24
quoteAnd so 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.↗
▶Ep 27 · 23:24
clinicalIf struggling with mesh placement during laparoscopic repair, the problem is inadequate dissection of the space, not oversized mesh; the solution is to remove mesh and dissect more widely.↗
▶Ep 27 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to permanent fixation.↗
▶Ep 27 · 24:20
clinicalIf absorbable tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 27 · 24:56
host_summaryThere is mounting evidence that medium-weight polypropylene mesh can be placed in contaminated fields, with several series in ventral hernias supporting this.↗
▶Ep 27 · 25:10
opinionBassini or McVay tissue repairs remain appropriate operations for contaminated fields.↗
▶Ep 27 · 25:55
clinicalFor incarcerated femoral hernia with bowel compromise, an infrainguinal vertical incision allows direct access to the hernia sac, bowel resection if needed, and reduction without dividing the inguinal ligament.↗
▶Ep 27 · 26:35
clinicalTo facilitate reduction of incarcerated femoral hernia contents, the lacunar ligament (medial to femoral space) can be released with scissors or bovie to gain an extra centimeter, avoiding destruction of the inguinal ligament.↗
▶Ep 27 · 27:20
clinicalReverse McVay repair for femoral hernia involves taking the inferior border of the inguinal ligament and sewing it down to Cooper's ligament from below, starting immediately lateral to the femoral vein to avoid impingement.↗
▶Ep 27 · 27:46
clinicalMesh plugs in femoral hernia repair can cause DVT due to irritation of the femoral vein, particularly in thin women who typically present with femoral hernias.↗
▶Ep 27 · 28:12
opinionFor recurrent hernias, operate where no prior surgery has been performed; if both spaces have been operated, choose the approach where you have the most skill.↗
▶Ep 27 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach, but surgeons learning laparoscopy should avoid bilateral and recurrent hernias as these are twice as hard despite potentially offering the most benefit.↗
▶Ep 27 · 29:09
opinionLarge inguinoscrotal hernias are managed with open operation; if truly incarcerated and cannot be reduced in office, open approach is used.↗
▶Ep 27 · 29:30
clinicalFor difficult-to-reduce but not truly incarcerated hernias, patient can be put to sleep for reduction under anesthesia, then TAPP repair performed; the internal ring can be cut laparoscopically at the two o'clock position (avoiding epigastric vessels) to facilitate reduction.↗
▶Ep 27 · 30:00
clinicalIf bowel holes are made during incarcerated hernia repair, the morbidity of the operation increases unacceptably high.↗
Inguinal Hernia With M. Rosen
▶Ep 28 · 2:10
quoteI 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.↗
▶Ep 28 · 3:22
host_summaryIn the Fitzgibbon 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%).↗
▶Ep 28 · 4:00
quoteSo 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.↗
▶Ep 28 · 4:00
host_summaryIn the Fitzgibbon study over two years, almost one-third of observed patients went on to develop symptoms and need an operation, and by five years almost three-quarters developed symptoms.↗
▶Ep 28 · 4:30
opinionFor an 89-year-old with asymptomatic hernia, observation is appropriate because in a couple years they might not have symptoms, but in younger patients the odds are against them living without it becoming symptomatic.↗
▶Ep 28 · 6:32
clinicalInguinal hernia repairs can be done under local anesthesia in patients with severe comorbidities, and it is worse for them to present with an emergency problem in the middle of the night.↗
▶Ep 28 · 8:20
quoteI 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.↗
▶Ep 28 · 9:00
host_summaryThere is a real learning curve to laparoscopic inguinal hernia repair, with some studies showing 200 to 250 cases required.↗
▶Ep 28 · 9:20
clinicalThe primary advantage of laparoscopy in skilled hands is that mesh is placed away from nerves, and the risk of chronic pain is lower than in open inguinal hernias.↗
▶Ep 28 · 9:40
quoteI think that how do you measure chronic pain in open inguinal hernias depends. If you do a very detailed survey, you'll have a very high incidence of chronic pain. If you just wait until patients come back and present with chronic pain, it will be lower. But those patients are absolutely miserable.↗
▶Ep 28 · 10:44
quoteI think the TEP pair, it's a little bit more expensive because you need to use the balloon. It's a little bit smaller of a space, but perhaps the angles are a little bit easier to operate with. I think a TAP, you get a little bit of a better view. You get a little bit more of a working space.↗
▶Ep 28 · 11:20
quoteThe way that I look at it is it's the same room. One comes through the front door. One comes through the ceiling. Ultimately, you work in the same space, and it should be the same operation regardless.↗
▶Ep 28 · 11:53
opinionFor young, healthy, active patients with unilateral hernia who are not anesthetic risks, laparoscopic repair is preferred in experienced hands, offering about a week to 10 days earlier recovery than open repair.↗
▶Ep 28 · 12:30
clinicalDisadvantages of laparoscopic repair include operating near intestines with risk of intestinal injury and risk of injury to major blood vessels, though these risks should be incredibly low if planes are known.↗
▶Ep 28 · 13:00
opinionIn elderly patients or anyone on anticoagulation who needs to restart quickly, open operation is preferred to avoid dissecting the retroperitoneal space.↗
▶Ep 28 · 14:09
opinionIn a 78-year-old patient with symptomatic hernia on one side and asymptomatic hernia discovered laparoscopically on the other side, the asymptomatic side should not be repaired due to doubled anesthetic time and increased hematoma risk.↗
▶Ep 28 · 14:58
opinionIn younger active patients, an asymptomatic contralateral hernia discovered laparoscopically should be repaired because the chance of it becoming symptomatic is much higher.↗
▶Ep 28 · 15:50
quoteI think that you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But you have to check your minimally invasive ego at the door.↗
▶Ep 28 · 16:26
opinionPrevious lower abdominal surgery increases risk of enterotomy and OR time for laparoscopic repair; if patient hasn't had open inguinal hernia, open approach is preferred.↗
▶Ep 28 · 16:55
opinionPrevious prostate surgery cases are unpredictable laparoscopically and can be brutal; in current practice these get open inguinal hernia repair.↗
▶Ep 28 · 17:58
clinicalThe most important part of any laparoscopic repair is parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly), a principle promoted by Rene Stoppa during open preperitoneal repairs.↗
▶Ep 28 · 18:10
quoteI 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.↗
▶Ep 28 · 18:40
quoteAnd 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.↗
▶Ep 28 · 18:40
clinicalThe inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view, scary to make holes, and taken very close off the vessels.↗
▶Ep 28 · 19:10
host_summaryAccording to Stoppa's original descriptions, for unilateral inguinal hernia repair, 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 meshes being placed.↗
▶Ep 28 · 20:40
opinionFor large direct hernias, mesh choice should change to a heavier weight material.↗
▶Ep 28 · 21:02
clinicalHeavyweight mesh is around 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, and lightweight (Ultrapro) is less than 30 grams per meter squared.↗
▶Ep 28 · 21:50
clinicalAdvantage of lighter weight mesh is less foreign body and less contraction; disadvantage is half the material with risk of fracturing, particularly in direct hernias where it's a bridge.↗
▶Ep 28 · 22:30
clinicalHeavier weight mesh rarely breaks but sometimes people feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 28 · 23:00
opinionFor inguinal hernia repair, should never use smaller than a large preformed mesh because you need to cover the whole myopectineal orifice.↗
▶Ep 28 · 23:00
quoteSo 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.↗
▶Ep 28 · 23:24
quoteAnd so 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.↗
▶Ep 28 · 23:24
clinicalIf struggling with mesh placement during laparoscopic repair, it's not that you're not a good enough laparoscopic surgeon, it's that you didn't dissect out the space enough - you need to take out the mesh and dissect bigger.↗
▶Ep 28 · 23:53
opinionMesh should be fixed in place; options include Protack tacks, glue, or no fixation, though for big direct hernias everybody uses fixation.↗
▶Ep 28 · 24:09
clinicalThere is no evidence that absorbable fixation causes reduction in pain, better fixation, or improved long-term outcomes; permanent fixation is used because if absorbable fixation goes through a nerve, it's the neuroma that causes the problem, not the tack.↗
▶Ep 28 · 24:09
quoteNo evidence that absorbable fixation causes reduction in pain, better fixation, or improve long-term outcomes. So I use permanent fixation. And absorbable fixation, if you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 28 · 24:56
host_summaryThere is mounting evidence that medium-weight polypropylene can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
▶Ep 28 · 25:55
clinicalFor incarcerated femoral hernia with bowel compromise, make a vertical incision for vascular-type exposure, dissect onto hernia sac, bring out compromised intestine infrainguinally, resect and anastomose, then reduce.↗
▶Ep 28 · 26:32
clinicalTo reduce incarcerated femoral hernia without dividing inguinal ligament, release the lacunar ligament medially (which gives off from the inguinal ligament) to gain an extra centimeter of space.↗
▶Ep 28 · 27:10
clinicalA 'reverse McVay' repair can be performed from below for femoral hernias, taking the inferior border of the inguinal ligament and sewing it down to Cooper's ligament starting immediately lateral to the femoral vein.↗
▶Ep 28 · 27:46
clinicalMesh plugs are not preferred for femoral hernias because femoral hernias tend to occur in thin women and there have been DVTs due to irritation on the femoral vein.↗
▶Ep 28 · 28:12
opinionFor recurrent hernias, operate where nobody has been before; if both spaces have been operated, go where you're best.↗
▶Ep 28 · 28:30
opinionFor bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach, but if learning, avoid bilateral and recurrent hernias laparoscopically because it makes it twice as hard despite these patients getting the most benefit.↗
▶Ep 28 · 29:09
opinionFor really big inguinal scrotal hernias that can't be reduced in office, open operation is preferred; when younger, these were done laparoscopically but now all done open.↗
▶Ep 28 · 29:40
clinicalFor incarcerated hernias, TAP approach is preferred over TEP because you want the contents out of the hernia; can laparoscopically cut the internal ring at the two o'clock position relative to epigastric vessels to help reduce.↗
quoteI 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.↗
▶Ep 1 · 2:17
quoteI 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.↗
▶Ep 1 · 2:38
quoteJust 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.↗
▶Ep 1 · 2:38
quoteJust 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.↗
▶Ep 1 · 3:30
epidemiologicalIn 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.↗
▶Ep 1 · 3:30
epidemiologicalIn 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.↗
▶Ep 1 · 4:11
epidemiologicalIn the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years.↗
▶Ep 1 · 4:11
epidemiologicalIn the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years.↗
▶Ep 1 · 4:21
epidemiologicalIn long-term follow-up of the Fitzgibbons study, almost three-fifths of patients in the observation group developed symptoms requiring operation by 5 years.↗
▶Ep 1 · 4:21
epidemiologicalIn long-term follow-up of the Fitzgibbons study, almost three-fifths of patients in the observation group developed symptoms requiring operation by 5 years.↗
▶Ep 1 · 4:33
opinionFor 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.↗
▶Ep 1 · 4:33
opinionFor 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.↗
▶Ep 1 · 4:36
opinionFor 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.↗
▶Ep 1 · 4:36
quoteThe 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.↗
▶Ep 1 · 4:36
opinionFor 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.↗
▶Ep 1 · 4:36
quoteThe 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.↗
▶Ep 1 · 6:06
quoteIt's much worse for them to present with an emergency problem in the middle of the night, which could be life threatening.↗
▶Ep 1 · 6:06
opinionFor 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.↗
▶Ep 1 · 6:06
opinionFor 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.↗
▶Ep 1 · 6:06
clinicalInguinal hernia repairs can be performed under local anesthesia in high-risk patients.↗
▶Ep 1 · 6:06
quoteIt's much worse for them to present with an emergency problem in the middle of the night, which could be life threatening.↗
▶Ep 1 · 6:06
clinicalInguinal hernia repairs can be performed under local anesthesia in high-risk patients.↗
▶Ep 1 · 7:56
clinicalFor unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support.↗
▶Ep 1 · 7:56
clinicalFor unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support.↗
▶Ep 1 · 8:29
opinionThe best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature.↗
▶Ep 1 · 8:29
opinionThe best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature.↗
▶Ep 1 · 9:04
opinionFor 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.↗
▶Ep 1 · 9:04
opinionFor 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.↗
▶Ep 1 · 9:04
epidemiologicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 1 · 9:04
epidemiologicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 1 · 9:18
clinicalIn 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.↗
▶Ep 1 · 9:18
clinicalIn 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.↗
▶Ep 1 · 9:51
clinicalChronic 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.↗
▶Ep 1 · 9:51
clinicalChronic 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.↗
▶Ep 1 · 10:45
epidemiologicalTAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes.↗
▶Ep 1 · 10:45
epidemiologicalTAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes.↗
▶Ep 1 · 10:58
clinicalTEP repair requires use of a balloon dissector, which is more expensive, and provides a smaller working space but perhaps easier angles to operate with.↗
▶Ep 1 · 10:58
clinicalTEP repair requires use of a balloon dissector, which is more expensive, and provides a smaller working space but perhaps easier angles to operate with.↗
▶Ep 1 · 11:09
clinicalTAPP 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.↗
▶Ep 1 · 11:09
clinicalTAPP 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.↗
▶Ep 1 · 11:26
clinicalTAPP 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.↗
▶Ep 1 · 11:26
clinicalTAPP 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.↗
▶Ep 1 · 12:11
quoteI 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.↗
▶Ep 1 · 12:11
quoteI 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.↗
▶Ep 1 · 12:23
quoteThe 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.↗
▶Ep 1 · 12:23
quoteThe 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.↗
▶Ep 1 · 12:23
clinicalLaparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair.↗
▶Ep 1 · 12:23
clinicalLaparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair.↗
▶Ep 1 · 12:45
clinicalLaparoscopic 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.↗
▶Ep 1 · 12:45
clinicalLaparoscopic 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.↗
▶Ep 1 · 13:06
quoteThe 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.↗
▶Ep 1 · 13:06
quoteThe 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.↗
▶Ep 1 · 13:28
opinionIn 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.↗
▶Ep 1 · 13:28
opinionIn 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.↗
▶Ep 1 · 14:10
opinionIn 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.↗
▶Ep 1 · 14:10
opinionIn 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.↗
▶Ep 1 · 15:17
clinicalPneumoperitoneum 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.↗
▶Ep 1 · 15:17
clinicalPneumoperitoneum 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.↗
▶Ep 1 · 15:39
opinionThe benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile.↗
▶Ep 1 · 15:39
opinionThe benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile.↗
▶Ep 1 · 15:55
quoteYou 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.↗
▶Ep 1 · 15:55
opinionSurgeons 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.↗
▶Ep 1 · 15:55
quoteYou 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.↗
▶Ep 1 · 15:55
opinionSurgeons 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.↗
▶Ep 1 · 16:24
opinionPrevious 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.↗
▶Ep 1 · 16:24
opinionPrevious 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.↗
▶Ep 1 · 16:42
opinionPrevious prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs.↗
▶Ep 1 · 16:42
opinionPrevious prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs.↗
▶Ep 1 · 17:52
clinicalBasic 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.↗
▶Ep 1 · 17:52
clinicalBasic 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.↗
▶Ep 1 · 18:15
clinicalParietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs.↗
▶Ep 1 · 18:15
clinicalParietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs.↗
▶Ep 1 · 18:27
clinicalThe 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.↗
▶Ep 1 · 18:27
clinicalThe 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.↗
▶Ep 1 · 18:53
clinicalThe 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.↗
▶Ep 1 · 18:53
clinicalThe 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.↗
▶Ep 1 · 18:56
quoteThe 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.↗
▶Ep 1 · 18:56
quoteThe 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.↗
▶Ep 1 · 19:03
clinicalWhen surgeons do not take the peritoneum far enough back inferiorly, they tend to use a smaller piece of mesh, which is problematic.↗
▶Ep 1 · 19:03
clinicalWhen surgeons do not take the peritoneum far enough back inferiorly, they tend to use a smaller piece of mesh, which is problematic.↗
▶Ep 1 · 19:30
clinicalAll mesh contracts to some degree and can move.↗
▶Ep 1 · 19:30
clinicalAll mesh contracts to some degree and can move.↗
▶Ep 1 · 19:40
quoteIf 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.↗
▶Ep 1 · 19:40
clinicalAccording 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.↗
▶Ep 1 · 19:40
quoteIf 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.↗
▶Ep 1 · 19:40
clinicalAccording 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.↗
▶Ep 1 · 20:26
opinionFor large direct inguinal hernias, mesh choice should change and surgeons should use a heavier weight material.↗
▶Ep 1 · 20:26
opinionFor large direct inguinal hernias, mesh choice should change and surgeons should use a heavier weight material.↗
▶Ep 1 · 21:37
clinicalMesh weight categories (heavyweight, midweight, lightweight) were defined by marketing companies, not based on science.↗
▶Ep 1 · 21:37
clinicalHeavyweight mesh is approximately 90 grams per meter squared (e.g., Marlex or Prolene).↗
▶Ep 1 · 21:37
clinicalHeavyweight mesh is approximately 90 grams per meter squared (e.g., Marlex or Prolene).↗
▶Ep 1 · 21:37
clinicalMesh weight categories (heavyweight, midweight, lightweight) were defined by marketing companies, not based on science.↗
▶Ep 1 · 21:57
clinicalLightweight mesh (Ultrapro) is less than 30 grams per meter squared, starting heavier but degrading over time to about 28 grams per meter squared.↗
▶Ep 1 · 21:57
clinicalMidweight mesh is between 40 to 50 grams per meter squared.↗
▶Ep 1 · 21:57
clinicalMidweight mesh is between 40 to 50 grams per meter squared.↗
▶Ep 1 · 21:57
clinicalLightweight mesh (Ultrapro) is less than 30 grams per meter squared, starting heavier but degrading over time to about 28 grams per meter squared.↗
▶Ep 1 · 22:16
clinicalAdvantages of lighter weight mesh include less foreign body, less palpability, and potentially less contraction because it ingrows more.↗
▶Ep 1 · 22:16
clinicalAdvantages of lighter weight mesh include less foreign body, less palpability, and potentially less contraction because it ingrows more.↗
▶Ep 1 · 22:23
clinicalDisadvantages 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.↗
▶Ep 1 · 22:23
clinicalDisadvantages 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.↗
▶Ep 1 · 22:42
clinicalHeavier weight mesh rarely breaks, but patients sometimes feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 1 · 22:42
clinicalHeavier weight mesh rarely breaks, but patients sometimes feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 1 · 22:51
clinicalPre-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.↗
▶Ep 1 · 22:51
clinicalPre-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.↗
▶Ep 1 · 23:08
opinionFor laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh because the entire myopectineal orifice needs to be covered.↗
▶Ep 1 · 23:08
opinionFor laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh because the entire myopectineal orifice needs to be covered.↗
▶Ep 1 · 23:24
clinicalIf the mesh is too big during laparoscopic inguinal hernia repair, the problem is not the mesh size but inadequate dissection of the space.↗
▶Ep 1 · 23:24
quoteIf 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.↗
▶Ep 1 · 23:24
clinicalIf the mesh is too big during laparoscopic inguinal hernia repair, the problem is not the mesh size but inadequate dissection of the space.↗
▶Ep 1 · 23:24
quoteIf 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.↗
▶Ep 1 · 23:53
opinionDr. Rosen believes mesh should be fixed in laparoscopic inguinal hernia repair and uses ProTack, though some surgeons use glue or no fixation.↗
▶Ep 1 · 23:53
opinionDr. Rosen believes mesh should be fixed in laparoscopic inguinal hernia repair and uses ProTack, though some surgeons use glue or no fixation.↗
▶Ep 1 · 23:59
clinicalEven surgeons who advocate no fixation will selectively use fixation for large direct hernias.↗
▶Ep 1 · 23:59
clinicalEven surgeons who advocate no fixation will selectively use fixation for large direct hernias.↗
▶Ep 1 · 24:10
epidemiologicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to non-absorbable fixation.↗
▶Ep 1 · 24:10
epidemiologicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to non-absorbable fixation.↗
▶Ep 1 · 24:22
clinicalIf a tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 1 · 24:22
quoteIf you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 1 · 24:22
clinicalIf a tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 1 · 24:22
quoteIf you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 1 · 24:30
opinionDr. Rosen performs Lichtenstein repair as his preferred open inguinal hernia technique.↗
▶Ep 1 · 24:30
opinionDr. Rosen performs Lichtenstein repair as his preferred open inguinal hernia technique.↗
▶Ep 1 · 24:56
epidemiologicalThere is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
▶Ep 1 · 24:56
epidemiologicalThere is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
▶Ep 1 · 25:01
opinionDepending on the level of contamination and indication, it is also appropriate to perform a Bassini or McVay repair without mesh in contaminated fields.↗
▶Ep 1 · 25:01
opinionDepending on the level of contamination and indication, it is also appropriate to perform a Bassini or McVay repair without mesh in contaminated fields.↗
▶Ep 1 · 25:55
opinionFor 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.↗
▶Ep 1 · 25:55
opinionFor 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.↗
▶Ep 1 · 26:36
clinicalTo 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.↗
▶Ep 1 · 26:36
clinicalTo 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.↗
▶Ep 1 · 27:19
opinionDr. 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.↗
▶Ep 1 · 27:19
opinionDr. 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.↗
▶Ep 1 · 27:44
opinionDr. 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.↗
▶Ep 1 · 27:44
opinionDr. 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.↗
▶Ep 1 · 28:12
opinionFor 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.↗
▶Ep 1 · 28:12
opinionFor 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.↗
▶Ep 1 · 28:31
opinionFor known bilateral inguinal hernias in a skilled laparoscopic surgeon's hands, laparoscopy is the preferred approach.↗
▶Ep 1 · 28:31
opinionFor known bilateral inguinal hernias in a skilled laparoscopic surgeon's hands, laparoscopy is the preferred approach.↗
▶Ep 1 · 28:36
opinionSurgeons 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.↗
▶Ep 1 · 28:36
opinionSurgeons 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.↗
▶Ep 1 · 29:10
opinionFor large inguinoscrotal hernias, Dr. Rosen now performs all repairs open, whereas when he was younger he did them laparoscopically.↗
▶Ep 1 · 29:10
opinionFor large inguinoscrotal hernias, Dr. Rosen now performs all repairs open, whereas when he was younger he did them laparoscopically.↗
▶Ep 1 · 29:23
opinionFor 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.↗
▶Ep 1 · 29:23
opinionFor 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.↗
▶Ep 1 · 29:30
opinionFor truly incarcerated hernias, TEP repair is not a good idea because surgeons want the hernia contents out of the sac; TAPP is preferred.↗
▶Ep 1 · 29:30
opinionFor truly incarcerated hernias, TEP repair is not a good idea because surgeons want the hernia contents out of the sac; TAPP is preferred.↗
▶Ep 1 · 29:43
clinicalSurgeons can laparoscopically cut the internal ring at the 2 o'clock position while watching the epigastric vessels to help reduce an incarcerated hernia.↗
▶Ep 1 · 29:43
clinicalSurgeons can laparoscopically cut the internal ring at the 2 o'clock position while watching the epigastric vessels to help reduce an incarcerated hernia.↗
▶Ep 1 · 29:53
opinionIf 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.↗
▶Ep 1 · 29:53
opinionIf 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.↗
quoteI 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.↗
▶Ep 10 · 2:17
quoteI 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.↗
▶Ep 10 · 2:38
quoteJust 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.↗
▶Ep 10 · 2:38
quoteJust 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.↗
▶Ep 10 · 3:30
epidemiologicalIn 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.↗
▶Ep 10 · 3:30
epidemiologicalIn 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.↗
▶Ep 10 · 4:11
epidemiologicalIn the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years.↗
▶Ep 10 · 4:11
epidemiologicalIn the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years.↗
▶Ep 10 · 4:21
epidemiologicalIn long-term follow-up of the Fitzgibbons study, almost three-fifths of patients in the observation group developed symptoms requiring operation by 5 years.↗
▶Ep 10 · 4:21
epidemiologicalIn long-term follow-up of the Fitzgibbons study, almost three-fifths of patients in the observation group developed symptoms requiring operation by 5 years.↗
▶Ep 10 · 4:33
opinionFor 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.↗
▶Ep 10 · 4:33
opinionFor 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.↗
▶Ep 10 · 4:36
quoteThe 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.↗
▶Ep 10 · 4:36
quoteThe 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.↗
▶Ep 10 · 4:36
opinionFor 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.↗
▶Ep 10 · 4:36
opinionFor 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.↗
▶Ep 10 · 6:06
clinicalInguinal hernia repairs can be performed under local anesthesia in high-risk patients.↗
▶Ep 10 · 6:06
quoteIt's much worse for them to present with an emergency problem in the middle of the night, which could be life threatening.↗
▶Ep 10 · 6:06
opinionFor 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.↗
▶Ep 10 · 6:06
quoteIt's much worse for them to present with an emergency problem in the middle of the night, which could be life threatening.↗
▶Ep 10 · 6:06
clinicalInguinal hernia repairs can be performed under local anesthesia in high-risk patients.↗
▶Ep 10 · 6:06
opinionFor 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.↗
▶Ep 10 · 7:56
clinicalFor unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support.↗
▶Ep 10 · 7:56
clinicalFor unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support.↗
▶Ep 10 · 8:29
opinionThe best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature.↗
▶Ep 10 · 8:29
opinionThe best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature.↗
▶Ep 10 · 9:04
opinionFor 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.↗
▶Ep 10 · 9:04
epidemiologicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 10 · 9:04
epidemiologicalThe learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.↗
▶Ep 10 · 9:04
opinionFor 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.↗
▶Ep 10 · 9:18
clinicalIn 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.↗
▶Ep 10 · 9:18
clinicalIn 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.↗
▶Ep 10 · 9:51
clinicalChronic 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.↗
▶Ep 10 · 9:51
clinicalChronic 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.↗
▶Ep 10 · 10:45
epidemiologicalTAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes.↗
▶Ep 10 · 10:45
epidemiologicalTAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes.↗
▶Ep 10 · 10:58
clinicalTEP repair requires use of a balloon dissector, which is more expensive, and provides a smaller working space but perhaps easier angles to operate with.↗
▶Ep 10 · 10:58
clinicalTEP repair requires use of a balloon dissector, which is more expensive, and provides a smaller working space but perhaps easier angles to operate with.↗
▶Ep 10 · 11:09
clinicalTAPP 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.↗
▶Ep 10 · 11:09
clinicalTAPP 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.↗
▶Ep 10 · 11:26
clinicalTAPP 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.↗
▶Ep 10 · 11:26
clinicalTAPP 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.↗
▶Ep 10 · 12:11
quoteI 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.↗
▶Ep 10 · 12:11
quoteI 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.↗
▶Ep 10 · 12:23
clinicalLaparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair.↗
▶Ep 10 · 12:23
quoteThe 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.↗
▶Ep 10 · 12:23
quoteThe 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.↗
▶Ep 10 · 12:23
clinicalLaparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair.↗
▶Ep 10 · 12:45
clinicalLaparoscopic 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.↗
▶Ep 10 · 12:45
clinicalLaparoscopic 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.↗
▶Ep 10 · 13:06
quoteThe 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.↗
▶Ep 10 · 13:06
quoteThe 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.↗
▶Ep 10 · 13:28
opinionIn 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.↗
▶Ep 10 · 13:28
opinionIn 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.↗
▶Ep 10 · 14:10
opinionIn 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.↗
▶Ep 10 · 14:10
opinionIn 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.↗
▶Ep 10 · 15:17
clinicalPneumoperitoneum 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.↗
▶Ep 10 · 15:17
clinicalPneumoperitoneum 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.↗
▶Ep 10 · 15:39
opinionThe benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile.↗
▶Ep 10 · 15:39
opinionThe benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile.↗
▶Ep 10 · 15:55
quoteYou 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.↗
▶Ep 10 · 15:55
opinionSurgeons 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.↗
▶Ep 10 · 15:55
quoteYou 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.↗
▶Ep 10 · 15:55
opinionSurgeons 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.↗
▶Ep 10 · 16:24
opinionPrevious 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.↗
▶Ep 10 · 16:24
opinionPrevious 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.↗
▶Ep 10 · 16:42
opinionPrevious prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs.↗
▶Ep 10 · 16:42
opinionPrevious prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs.↗
▶Ep 10 · 17:52
clinicalBasic 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.↗
▶Ep 10 · 17:52
clinicalBasic 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.↗
▶Ep 10 · 18:15
clinicalParietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs.↗
▶Ep 10 · 18:15
clinicalParietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs.↗
▶Ep 10 · 18:27
clinicalThe 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.↗
▶Ep 10 · 18:27
clinicalThe 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.↗
▶Ep 10 · 18:53
clinicalThe 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.↗
▶Ep 10 · 18:53
clinicalThe 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.↗
▶Ep 10 · 18:56
quoteThe 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.↗
▶Ep 10 · 18:56
quoteThe 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.↗
▶Ep 10 · 19:03
clinicalWhen surgeons do not take the peritoneum far enough back inferiorly, they tend to use a smaller piece of mesh, which is problematic.↗
▶Ep 10 · 19:03
clinicalWhen surgeons do not take the peritoneum far enough back inferiorly, they tend to use a smaller piece of mesh, which is problematic.↗
▶Ep 10 · 19:30
clinicalAll mesh contracts to some degree and can move.↗
▶Ep 10 · 19:30
clinicalAll mesh contracts to some degree and can move.↗
▶Ep 10 · 19:40
quoteIf 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.↗
▶Ep 10 · 19:40
clinicalAccording 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.↗
▶Ep 10 · 19:40
clinicalAccording 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.↗
▶Ep 10 · 19:40
quoteIf 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.↗
▶Ep 10 · 20:26
opinionFor large direct inguinal hernias, mesh choice should change and surgeons should use a heavier weight material.↗
▶Ep 10 · 20:26
opinionFor large direct inguinal hernias, mesh choice should change and surgeons should use a heavier weight material.↗
▶Ep 10 · 21:37
clinicalMesh weight categories (heavyweight, midweight, lightweight) were defined by marketing companies, not based on science.↗
▶Ep 10 · 21:37
clinicalHeavyweight mesh is approximately 90 grams per meter squared (e.g., Marlex or Prolene).↗
▶Ep 10 · 21:37
clinicalMesh weight categories (heavyweight, midweight, lightweight) were defined by marketing companies, not based on science.↗
▶Ep 10 · 21:37
clinicalHeavyweight mesh is approximately 90 grams per meter squared (e.g., Marlex or Prolene).↗
▶Ep 10 · 21:57
clinicalLightweight mesh (Ultrapro) is less than 30 grams per meter squared, starting heavier but degrading over time to about 28 grams per meter squared.↗
▶Ep 10 · 21:57
clinicalMidweight mesh is between 40 to 50 grams per meter squared.↗
▶Ep 10 · 21:57
clinicalLightweight mesh (Ultrapro) is less than 30 grams per meter squared, starting heavier but degrading over time to about 28 grams per meter squared.↗
▶Ep 10 · 21:57
clinicalMidweight mesh is between 40 to 50 grams per meter squared.↗
▶Ep 10 · 22:16
clinicalAdvantages of lighter weight mesh include less foreign body, less palpability, and potentially less contraction because it ingrows more.↗
▶Ep 10 · 22:16
clinicalAdvantages of lighter weight mesh include less foreign body, less palpability, and potentially less contraction because it ingrows more.↗
▶Ep 10 · 22:23
clinicalDisadvantages 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.↗
▶Ep 10 · 22:23
clinicalDisadvantages 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.↗
▶Ep 10 · 22:42
clinicalHeavier weight mesh rarely breaks, but patients sometimes feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 10 · 22:42
clinicalHeavier weight mesh rarely breaks, but patients sometimes feel it in their groin if there are wrinkles or buckles, which can cause issues.↗
▶Ep 10 · 22:51
clinicalPre-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.↗
▶Ep 10 · 22:51
clinicalPre-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.↗
▶Ep 10 · 23:08
opinionFor laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh because the entire myopectineal orifice needs to be covered.↗
▶Ep 10 · 23:08
opinionFor laparoscopic inguinal hernia repair, surgeons should never use smaller than a large pre-formed mesh because the entire myopectineal orifice needs to be covered.↗
▶Ep 10 · 23:24
clinicalIf the mesh is too big during laparoscopic inguinal hernia repair, the problem is not the mesh size but inadequate dissection of the space.↗
▶Ep 10 · 23:24
quoteIf 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.↗
▶Ep 10 · 23:24
clinicalIf the mesh is too big during laparoscopic inguinal hernia repair, the problem is not the mesh size but inadequate dissection of the space.↗
▶Ep 10 · 23:24
quoteIf 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.↗
▶Ep 10 · 23:53
opinionDr. Rosen believes mesh should be fixed in laparoscopic inguinal hernia repair and uses ProTack, though some surgeons use glue or no fixation.↗
▶Ep 10 · 23:53
opinionDr. Rosen believes mesh should be fixed in laparoscopic inguinal hernia repair and uses ProTack, though some surgeons use glue or no fixation.↗
▶Ep 10 · 23:59
clinicalEven surgeons who advocate no fixation will selectively use fixation for large direct hernias.↗
▶Ep 10 · 23:59
clinicalEven surgeons who advocate no fixation will selectively use fixation for large direct hernias.↗
▶Ep 10 · 24:10
epidemiologicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to non-absorbable fixation.↗
▶Ep 10 · 24:10
epidemiologicalThere is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to non-absorbable fixation.↗
▶Ep 10 · 24:22
clinicalIf a tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 10 · 24:22
quoteIf you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 10 · 24:22
clinicalIf a tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.↗
▶Ep 10 · 24:22
quoteIf you put it through the nerve, it's the neuroma that causes the problem, not the attack.↗
▶Ep 10 · 24:30
opinionDr. Rosen performs Lichtenstein repair as his preferred open inguinal hernia technique.↗
▶Ep 10 · 24:30
opinionDr. Rosen performs Lichtenstein repair as his preferred open inguinal hernia technique.↗
▶Ep 10 · 24:56
epidemiologicalThere is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
▶Ep 10 · 24:56
epidemiologicalThere is mounting evidence that medium weight polypropylene mesh can be placed in a contaminated field, with several series in ventral hernias supporting this.↗
▶Ep 10 · 25:01
opinionDepending on the level of contamination and indication, it is also appropriate to perform a Bassini or McVay repair without mesh in contaminated fields.↗
▶Ep 10 · 25:01
opinionDepending on the level of contamination and indication, it is also appropriate to perform a Bassini or McVay repair without mesh in contaminated fields.↗
▶Ep 10 · 25:55
opinionFor 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.↗
▶Ep 10 · 25:55
opinionFor 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.↗
▶Ep 10 · 26:36
clinicalTo 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.↗
▶Ep 10 · 26:36
clinicalTo 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.↗
▶Ep 10 · 27:19
opinionDr. 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.↗
▶Ep 10 · 27:19
opinionDr. 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.↗
▶Ep 10 · 27:44
opinionDr. 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.↗
▶Ep 10 · 27:44
opinionDr. 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.↗
▶Ep 10 · 28:12
opinionFor 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.↗
▶Ep 10 · 28:12
opinionFor 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.↗
▶Ep 10 · 28:31
opinionFor known bilateral inguinal hernias in a skilled laparoscopic surgeon's hands, laparoscopy is the preferred approach.↗
▶Ep 10 · 28:31
opinionFor known bilateral inguinal hernias in a skilled laparoscopic surgeon's hands, laparoscopy is the preferred approach.↗
▶Ep 10 · 28:36
opinionSurgeons 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.↗
▶Ep 10 · 28:36
opinionSurgeons 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.↗
▶Ep 10 · 29:10
opinionFor large inguinoscrotal hernias, Dr. Rosen now performs all repairs open, whereas when he was younger he did them laparoscopically.↗
▶Ep 10 · 29:10
opinionFor large inguinoscrotal hernias, Dr. Rosen now performs all repairs open, whereas when he was younger he did them laparoscopically.↗
▶Ep 10 · 29:23
opinionFor 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.↗
▶Ep 10 · 29:23
opinionFor 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.↗
▶Ep 10 · 29:30
opinionFor truly incarcerated hernias, TEP repair is not a good idea because surgeons want the hernia contents out of the sac; TAPP is preferred.↗
▶Ep 10 · 29:30
opinionFor truly incarcerated hernias, TEP repair is not a good idea because surgeons want the hernia contents out of the sac; TAPP is preferred.↗
▶Ep 10 · 29:43
clinicalSurgeons can laparoscopically cut the internal ring at the 2 o'clock position while watching the epigastric vessels to help reduce an incarcerated hernia.↗
▶Ep 10 · 29:43
clinicalSurgeons can laparoscopically cut the internal ring at the 2 o'clock position while watching the epigastric vessels to help reduce an incarcerated hernia.↗
▶Ep 10 · 29:53
opinionIf 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.↗
▶Ep 10 · 29:53
opinionIf 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.↗
