Low Cardiac Output
With Jeffrey Ponsky · Michael Rosen
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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Inguinal Hernia: Adult
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Dr Michael Rosen discusses Adult Inguinal Hernias with Dr Jeffrey Ponsky Edited by Harveen LambaIntroductions:Dr. Ponsky, professor of surgery at the Cleveland Clinic Lerner College of Medicine and Department of Surgery and Dr. Michael Rose
podcast31:02 · Dec 2020
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I cannot produce a living summary for "Low Cardiac Output" from the provided claim ledger because every claim in the ledger concerns inguinal and femoral hernia repair—not cardiac physiology or low cardiac output states. The ledger discusses hernia incarceration risk , symptom progression in asymptomatic hernias [e3441-c2, e3441-c3], laparoscopic versus open repair techniques [e3441-c4 through e3441-c10], mesh selection by weight and size [e3441-c11 through e3441-c17], fixation methods [e3441-c18, e3441-c19], contaminated field management , femoral hernia reduction , and recurrent hernia strategy [e3441-c22 through e3441-c24]. None of these claims address cardiac output, hemodynamics, inotropic support, mechanical circulatory support, or any cardiovascular topic. To write an evidence-based summary on low cardiac output, I require claims extracted from discussions of that clinical domain.
- Asymptomatic inguinal hernias carry 0.3% emergency operation risk but 60% develop symptoms by 5 years, informing watchful waiting decisions.
- Laparoscopic repair places mesh away from nerves, reducing chronic pain and accelerating recovery by 7–10 days versus open, but risks visceral/vascular injury.
- Mesh weight matters: heavyweight (≥90 g/m²) for large direct defects; lightweight (<30 g/m²) risks fracture when bridging.
- Parietalization and inferior dissection are critical laparoscopic steps; use ≥15×15 cm mesh to cover the entire myopectineal orifice.
- For incarcerated hernias prefer TAPP over TEP to evacuate sac contents; release lacunar ligament for femoral hernia reduction without destroying inguinal ligament.
For patients & families
When doctors talk about inguinal hernias in older adults, they explain that most hernias that don't cause symptoms have a very low chance—only about 3 in 1,000—of suddenly becoming a surgical emergency . However, over time many hernias do start causing discomfort: about one-third of patients develop symptoms within two years, and nearly three-fifths by five years [e3441-c2, e3441-c3]. Surgeons can repair these hernias using different approaches. Some repairs are done through small incisions using a camera (laparoscopic repair), which typically allows patients to recover about one to two weeks faster than traditional open surgery . The laparoscopic approach also places the mesh patch away from nerves, which may reduce long-term pain . However, this technique requires significant training—surgeons need to perform 200 to 250 cases to become proficient—and carries risks of injury to the intestines or blood vessels because the surgery is done near these structures [e3441-c5, e3441-c8]. For patients with complicated hernias, such as those that have come back after previous repair, surgeons carefully choose their approach based on what has been tried before and where they have the most experience .
When doctors talk about inguinal hernias in older adults, they explain that most hernias that don't cause symptoms have a very low chance—only about 3 in 1,000—of suddenly becoming a surgical emergency . However, over time many hernias do start causing discomfort: about one-third of patients develop symptoms within two years, and nearly three-fifths by five years [e3441-c2, e3441-c3]. Surgeons can repair these hernias using different approaches. Some repairs are done through small incisions using a camera (laparoscopic repair), which typically allows patients to recover about one to two weeks faster than traditional open surgery . The laparoscopic approach also places the mesh patch away from nerves, which may reduce long-term pain . However, this technique requires significant training—surgeons need to perform 200 to 250 cases to become proficient—and carries risks of injury to the intestines or blood vessels because the surgery is done near these structures [e3441-c5, e3441-c8]. For patients with complicated hernias, such as those that have come back after previous repair, surgeons carefully choose their approach based on what has been tried before and where they have the most experience .
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Inguinal Hernia: Adult
In the Fitzgibbons VA study of minimally symptomatic to asymptomatic inguinal hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration or strangulation) requiring operation was 0.3% over 2 years.
epidemiologicalMichael Rosen3:30 ↗
In the Fitzgibbons study, almost one-third of patients in the observation group developed symptoms requiring operation by 2 years.
epidemiologicalMichael Rosen4:11 ↗
In long-term follow-up of the Fitzgibbons study, almost three-fifths of patients in the observation group developed symptoms requiring operation by 5 years.
epidemiologicalMichael Rosen4:21 ↗
For an 89-year-old patient with an asymptomatic hernia, watchful waiting is acceptable because the odds are they may not develop symptoms over their remaining lifespan.
opinionMichael Rosen4:33 ↗
For younger patients with asymptomatic hernias, the odds are against them living the rest of their life without the hernia becoming symptomatic, so repair should be recommended when the time is right.
opinionMichael Rosen4:36 ↗
Inguinal hernia repairs can be performed under local anesthesia in high-risk patients.
clinicalMichael Rosen6:06 ↗
For symptomatic hernias in high-risk patients, it is much worse for them to present with an emergency problem in the middle of the night, which could be life-threatening, so they should still be offered repair.
opinionMichael Rosen6:06 ↗
For unilateral primary inguinal hernias, tissue repair, open mesh repair, or laparoscopic mesh repair are all acceptable approaches with ample literature support.
clinicalMichael Rosen7:56 ↗
The best approach for inguinal hernia repair is what the surgeon does best, and this is supported by literature.
opinionMichael Rosen8:29 ↗
The learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.
epidemiologicalMichael Rosen9:04 ↗
In laparoscopic inguinal hernia repair, the mesh is placed away from the nerves, and the risk of chronic pain is lower than in open inguinal hernia repair when done correctly.
clinicalMichael Rosen9:18 ↗
Chronic pain after open inguinal hernia repair can occur due to technical problems or simply due to mesh laying on the nerves, and affected patients are absolutely miserable.
clinicalMichael Rosen9:51 ↗
For young, healthy patients with unilateral hernias who are not anesthetic risks, laparoscopic repair is preferred by Dr. Rosen if the surgeon is past the learning curve.
opinionMichael Rosen9:04 ↗
TAPP (transabdominal preperitoneal) and TEP (total extraperitoneal) approaches have not been studied well enough to provide level-one evidence distinguishing their outcomes.
epidemiologicalMichael Rosen10:45 ↗
TEP repair requires use of a balloon dissector, which is more expensive, and provides a smaller working space but perhaps easier angles to operate with.
clinicalMichael Rosen10:58 ↗
TAPP repair provides a better view and larger working space, and makes it easier for surgeons early in their learning curve to look intraperitoneally and confirm hernia reduction.
clinicalMichael Rosen11:09 ↗
TAPP and TEP ultimately work in the same anatomical space—one enters through the front door, one through the ceiling—and should result in the same operation.
clinicalMichael Rosen11:26 ↗
Laparoscopic inguinal hernia repair offers approximately 1 week to 10 days earlier recovery compared to open repair.
clinicalMichael Rosen12:23 ↗
Laparoscopic inguinal hernia repair carries a risk of intestinal injury and injury to major blood vessels because the operation is performed near these structures, but this risk should be incredibly low if the surgeon knows the planes and operates safely.
clinicalMichael Rosen12:45 ↗
In elderly patients with any anesthetic risk or anyone on anticoagulation who needs to restart quickly, Dr. Rosen prefers open repair because he does not want to dissect the retroperitoneal space in these patients.
opinionMichael Rosen13:28 ↗
In a 78-year-old patient with a symptomatic hernia on one side and an asymptomatic hernia discovered laparoscopically on the other side, Dr. Rosen does not fix the asymptomatic side, citing concerns about doubling anesthetic time and increasing hematoma risk.
opinionMichael Rosen14:10 ↗
Pneumoperitoneum is rarely a problem in patients with reduced cardiac capacity as long as insufflation is done slowly, pressures are kept low, and the patient is positioned in Trendelenburg to help cardiac return.
clinicalMichael Rosen15:17 ↗
The benefits of laparoscopy for inguinal hernia repair are small for the vast majority of patients, though still worthwhile.
opinionMichael Rosen15:39 ↗
Surgeons must check their minimally invasive ego at the door and ensure they can also perform open inguinal hernias or refer to someone who can, rather than pushing laparoscopy in sick comorbid patients simply because it is their go-to approach.
opinionMichael Rosen15:55 ↗
Previous lower abdominal surgery is a contraindication to laparoscopic inguinal hernia repair in Dr. Rosen's practice because it increases the risk of enterotomy and OR time.
opinionMichael Rosen16:24 ↗
Previous prostate surgery makes laparoscopic inguinal hernia repair unpredictable—sometimes straightforward, sometimes brutal—and Dr. Rosen now performs these as open repairs.
opinionMichael Rosen16:42 ↗
Basic tenets of laparoscopic inguinal hernia repair include achieving a wide dissection plane, with parietalization of the cord (stripping peritoneum off the cord inferiorly and posteriorly) being the most critical element.
clinicalMichael Rosen17:52 ↗
Parietalization of the cord is a basic principle promoted by René Stoppa during open preperitoneal repairs.
clinicalMichael Rosen18:15 ↗
The length of parietalization is critical because it prevents the peritoneum from coming under the mesh and going back out to the defect, which is the mechanism of recurrence.
clinicalMichael Rosen18:27 ↗
The inferior dissection is the Achilles heel of any laparoscopic inguinal hernia repair because it is awkward to view, surgeons fear making holes in the peritoneum, and it requires dissection very close to the vessels.
clinicalMichael Rosen18:53 ↗
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