Chapters Transcript Live Mesh and Hernia Surgical Repair Dr. Sean P. Harbison, MD, MSEd, performs a surgical mesh and hernia repair live from Penn Presbyterian Medical center. Hello, scholars. Welcome to Philadelphia, where at Penn Presbyterian Medical Center in West Philadelphia. It's part of the pen system, and my name is Sean Harbison, and I'm a general surgeon. Standing across from me is Nate Belkin, MD. Who is a surgical resident. Actually, he's sort of slotted to be a vascular surgeon eventually. And, uh, if we can go around the room and introduce everybody, it's a big team that takes care of a patient who is undergoing an operation. The gentleman we're gonna operate eight is is a A gentleman who unfortunately, suffered a gunshot wound to his abdomen in 2003. So, uh, 16 years ago and part of the treatment of his, um care, part of his treatment was that he had abdominal surgery. He had a complication of the surgery, which was a hernia, which is when the incision sort of stretches out and weakens. And he had at least two repairs of that hernia with mesh. You may have heard about mesh being placed on TV. Uh, and the mesh that was placed in his abdomen became infected and eroded into the bowel and is now leaking. So it's a chronic infection with a connection to the bowel. So our job today is to get rid of that mesh so the infection will heal. Fix the bell and fix his hernia Generally. Well, you could do a CT scan, which would show a hernia. Um, and if you look, if you guys look in here, you can see the mesh right here. There's actually I can see two different meshes. So some somebody put a mesh on, and then some other person are the same person for the second coating on underneath the just And obviously it didn't work, and that's why we're here. Usually you can go to here now. You can exercise all of it. Usually the patient shows up with pain or a mass, Um, and then you can do an X ray. A CT is probably the best X ray to do, but it's what we call a clinical diagnosis, meaning patient shows up in you. Examine the patient and you can detect it with your hands. Hernias are all types of hernias are amongst the top three operations general surgery operations done in the United States, a gall bladder removal hernia And an appendectomy or the top three followed closely. Bye. Uh, gastric bypass operation for obesity. You can go to here. So of all and of all hernias, um, England, all hernias are the most common and most England hernias occur in in males. Because males have males or males, they have testicles. Any hernia is nothing more than a weakness in the strength layer of the abdominal wall. So any cut is a natural, weak point. And you can see in here that hopefully you can see in here with this mesh. There's a bunch of sort of grungy, gnarly looking fluid that's sitting there, and that's as infected. That's his infection right there. That that little greenish part. And we don't know yet whether it's all hooked to the bowel because we haven't gotten that far yet. We're trying as hard as we can trust us. Yeah. Yes. Um, we we back into, like, the late 80s into the 90s. We thought that mesh was like the be all and end all and was like the answer to fix hernias. And but now we're seeing that there's more problems with mess when you put it inside. Most inguinal hernias are fixed with mesh but we're trying to use mesh less and less now with abdominal wall hernias. Okay, just because of this reason, collective effect that they cause infection. Yeah, and they cause problems with the bowel. Have a mess. Thank you. Come on. No, anything, Anything is fair game. Well, almost anything. Keep that in mind. Uh huh. What did you first? That's a great question. Um, I think, uh, we have to deliver bad news often, unfortunately, and I think trying to be sensitive trying to be honest, um, trying to be optimistic, but truthful, um is the is the best way to go. Um, it's certainly not a fun part of the job. Um, when we're doing surgery, you know, I'm asking people we are asking people to let us cut them and potentially hurt them. They have to trust us. And that's part of what I was talking about. This is a a people job, and right now I'm doing a thing called licensing adhesions. This is the bow. In fact, this is the colon right here, and it's filled with air. You guys know what that is? If he passes it from below? Um uh, and it's all stuck to the abdominal wall, and it's usually not. So what we're doing is we're freeing it up. Because here's here's here's the mesh. And this is Old Scar. Yeah. I don't know how we're gonna Yeah. Mhm. Yeah, Absolutely. Can I have a four set? So, yeah, this this is all mesh here, and maybe you can see the pattern to it, Uh, my fingers under it. And this brown and green part is actually, I think the fistula, because what's inside of your bowel is is greenish because there's bile stood out. This problem. Yeah, Yeah, I would say all of them right there. He Well, he was originally shot In 2003, So 16 years ago, And I think his last his first Hernia operation was in 2010, and then they 2nd 1, I believe, was in 2014. Yeah. Come. Huh? Find out. Uh huh. All right. Hopefully we're going to take it out in one piece. And yes, part of our our our dilemma is you say you say Okay, Sean. Okay, Nate, we got the mesh out. Now what? Uh, now hernia. How are we going to fix that and knowing that if we kind of a male knowing that if we put more mesh in there, um, another infection will more than likely occur. So we have to part of our job. Part of the hard part of the job is to to figure out Well, yeah, is too fix his hernia. And we know going into this we might not even be able to fix this hernia, and we might actually leave him with a hernia. And guys, you can see. Remember, all this was tacked down. And thanks to Dr Belkin's great help, uh, we're way over on the side. Here. There's different types of mesh. There's this time it's called permanent Mesh. It's synthetic. It's made out of polypropylene plastic. Ah, and there is a mesh that's made out of the same stuff that melt away Searchers are made out of. Ah, and there's possibility that we could use that to help close that mesh gets absorbed by your body within about pretty nice. I get down there within about a year. That is just, uh, yeah, within about a year. There's also Meshed that's made out of ah, human Dermish. Human cells that they grow in a lab and prepare so it that so we can use them. And thats biologic mesh. Thats that's extremely expensive. Meaning a piece of mesh probably. Um, five x 7" is probably about 3000. $5000. Yeah, Yeah, but it's worth it if you can, if you're going to get a result. Good result. Yeah, about not mhm. The the the mesh that gets absorbed and goes away has less risks. Because if there is an infection and by definition, this isn't Yeah, it will. It's more forgiving. Meaning it will. It will eventually go away. Some of this I'm doing finger fracture. Put your sucking out here. Mhm. Yeah. Uh huh. Call it question. Uh huh. Like, you know, transport best, but on tell me where. Yeah, Where? Okay, great question. Skin. This is an African American gentleman. So skin is easy to see. The subcutaneous tissue right here. The yeah, tissue here, Russia. And this is the midline, so it's only one layer. And then once we get below the fascia, this layer of lining this glistening layer, we call it the peritoneum. Um and it doesn't look very good. It Looks like there's old mesh in there too, Right? Ready? Yeah. Uh, well, there's a lot of evidence of scarring that he has. And that's just because, you know, he's had this is his At least his 4th operation. Those mayors again. I got him. Yeah, Mhm. And we're just working on getting this, uh, getting this mesh out. Mhm. Um, right now, me. No, I don't. I mean, originally. Yeah, yeah, sure. Scholars who are stop here. No. Yeah, absolutely. Plus, we wear masks, so it's, like, sort of breathing into a bag. Um, and, you know, it's not at all unusual. Um, if you're tired or if you haven't eaten that you is happens to a lot of people. It happens to a lot of people in the O. R that they're excited. Um, we're I'm you see us doing sort of like barbaric things, right? Mhm time for that? Yeah. Yeah, All correct. There's his, uh that might be a fit. So, uh, yeah, Mhm. Mhm. So we're right down in the fistula now. See, this is all the the bad stuff, and we think we might You might see it right there, But again, it's so scarred that it's It's hard to tell fire. Yeah, it is. You guys are super perceptive. Okay, Right. Morning. I think that's the bottom of the nest. Your finger there? Yeah. Why? Right, sorry. Dollars. Public industry areas. So large. Have you ever one. Oh, yeah. There's so many stories while no junior mints or anything, but that's yeah, uh, spell. So be careful. So there's more bow here, but now we're below the mesh. So we're actually believe it or not, we're making progress. This looks This looks like I know it looks like a bomb went off. Um, I thankfully, I've never lost anything in the abdomen. I've I've certainly gone in. There it is right there. That's the fistula right there, guys. I mean, you can't You can't Really? Yeah. If you look really closely, this looks like normal bowel here. Okay? And this looks like sort of like a gaping fish mouth or something that I can put my scissor tip into, or I can put my finger into. So there's an open piece of bowel there. All right. So the bowel was against this mesh, and we're still going to have to get all of this free to get this loop of the Belfry and probably take a segment out and put it back together. And right now at least I'm thinking out loud. And I'm thinking for you guys, I would be against putting any mesh back in here. I would be in favor of just closing it up with futures and if he would get to get a hernia. I mean, I'm sorry. We can come back another day, but and all of this stuff is unrecognizable because it's just scarred tissue chronically scarred because the bell was leaking into this cavity and then leaking through the mesh and then leaking through his abdominal wall. Okay, you can start cutting that off. Yeah, Yeah, one there. Probably not. He'll be in the hospital for I would say at least five days. Well, yeah. This is a big, pretty big operation we're doing. Yeah, I know. Yeah. Mhm. Yeah. Now you can see the see the mess here. It's a couple of different pieces of mesh, and it's still attached to this side of the abdominal wall. And we still have all of this goop here can have a schnitzel eat and we don't want to just blast in there. Um, because we really don't want to injure any more bowel. Yes, right there. Huh? Asked what was your first? Very right. Uh, that's a good question. So left. Yeah, I don't. I apologize. But most of what I do, It would be like in England. A hernia, which takes, like, 20 minutes. And tomorrow we're gonna if you guys are we're broadcasting, we're going to do a robotic hernia. Um, they're much more common. I mean, this is a big operation, and I started doing surgery as an attending in 1993. So I've been doing this for a long time, and I don't I don't really remember my first hernia. I do. Usually I do about 15- 20 operations per week. That's about a normal week for me. No, I think so. I don't know what you busy. Maybe. Maybe so. I think I think a really busy year for me, and I do. So there's the mesh that we took out. Can you see that? Yeah. Ah, yeah. I think we may have left some fragments in there. In fact, I know we did that are like, incorporate. There's like a little piece right there, Um, that are incorporated into the abdominal wall. And so there's the colon. This is all scar tissue from this fistula that we're going to have to negotiate somehow. So just because I'm on this side of the patient, I've had the chance to work into here the most, but we're gonna have to do that over here. Neither met. Yeah? Yeah. Started. Take it out. Yeah. Yeah, well, we have to release this because we have to fix this hole in the bowel somehow. Um, I'm not going to be mhm this. Yeah, yeah, that little gaping opening. And we would say I would say that we taken down the fistula, but now we have to somehow repair it, and then we're I'm gonna We're not gonna mess around and spend a lot of time trying to do a hernia repair. Um, I actually don't. He had much of a hernia. To be honest with you, I think his main problem was this infected mesh. And yeah, you say there's his abdominal wall on his right. There's his abdominal wall, and I'm grabbing the fascia. And that closes up really easily without any tension. So once we fix this, we're just gonna close it up, okay? You think about booking? Yeah. Uh, yeah. Thank you. We're gonna, um we're gonna set up an instrument that we call a book. Walter, I will use it after. Ah, Max is really good. He knows what he's doing. Part of, um, his job is to is to know what is. Yeah, held in the operation. And so he asked me earlier. That's reckless. What? I need a this instrument. Call the book, Walter, and we'll show you guys what that is. It's a type of a retractor. That's that's yeah. Hey, it had simply Yeah. What is that? Yeah, that's it. Yeah. It's named after a dude by the name of book Walter. Um, not Walter. His last name was book Walter and I actually met him once. He lived in a little town called Brattleboro, Vermont, and he was the only surgeon, like within miles and miles. Oh, look at this. You guys, I don't know if you guys can see this, but I just hit the mother lode. It's freedom freedom. So I broke into a space down here that's completely free. And here's here's small intestine and that's free. So I love that because now I have I have a face that I can run with the ball. It's almost like, I don't know, uh, sports, sports metaphors. I got the football. I have open field in front of me. Nothing but green grass and the goal line. Is that too corny here? Yeah, Yeah, yeah, yeah. So? So it can go faster and it can, and it tells us where we are. So now we're now every little sniff I make. I'm not worrying about, like, cutting into the bow and causing, uh, injury. So mhm. Look here, that's that's intestine. This is called That's called the peritoneum, which is the lining of the inside of your abdomen. This right here is his. You can't tell, but it it kind of you can lift that up, was gonna grab it. Kind of looks like, um, some meat. And it is That's his six pack muscle right there. And we call that his rectus muscle, and that runs along here, and we cut into it inadvertently. But, uh, that I don't Who cares? No, that. Yeah, that'll heal up. No problem. So we're making pretty good progress before. Love it. That little almost called out for you. Yeah, this is a piece of the bowel. Okay, All of these loops are bowel bowel loops. Uh, here's a piece of mesh and you can see how sticky it is. The bowel is is hooked onto it, so we're gonna have to take that out, too. That's a piece of mesh that we didn't get. I'm serious this time, right? Slow down. Oh, well, it could. That's a great question. Who was that? A student, or was that you? I'm wondering. Okay. Yeah. No, that's great. You're You're facilitating discussion. So if you had a adhesions, that's all messed if you had adhesions. Hey, very often because, uh, a bowel obstruction. So the bowel, it's scarred in a certain way. Like, say, if you took your garden hose and you bend it in half and put a rubber band around it, that's sort of what and adhesion does. And it can cause a bowel blockage. This is all all mesh in here that probably should be removed eventually by us. I would think Mhm. Okay. Yeah. So, usually in an operation, it's not just don't think it's like, Oh, this is harvesting. Just, like talks the entire Usually everybody's talking. You guys can't hear it, but we have a We have a radio on in the background. I like to have music. Some surgeons don't so mhm. You can see how it goes. Oh, really? Yeah. Well, Max's side job is he's, uh He's a front man in his own band, so Yeah. Yeah. And lives. And, uh, Nate, um, played. You played golf, right? Right? Yeah. And he's a super athlete, and so So we all have stuff we like to do. I mean, we don't we don't You don't have to be like a monk when you're when you work in health care, you can have a actually even better to have a life because it's like self care. It's like stuff you you like to do, right? No, we have. Mm. Or Grandpa? What? What's called character work care provider? Uh huh. Yeah. No. Right. Okay. Right. Right. So it's something outlet. Exactly. Yeah, Yeah. Can you Can you hear if if if Nate were to talk, can you hear him through my mic, or should we Mike him and then we can certainly ask Max to to weigh in. What is that for a while, and I'm happy to. I don't I don't want you to think it's all about me. Certainly not. Go ahead. Can relax. That or not, we can start on this. So while while we're setting up a mic for Nate because Nate's a resident and residency is hard, I would go right on my finger. Um, and I think I think Nate works a lot harder than me nine. And I'm I'm older. I'm 59. I think that Yeah. Oh, you know exactly what to say. All right, take this time. Get in here. Has spent the hurry. Yeah. Yep. Do it. Yeah. So if you guys have suddenly noticed Yeah, Operation sort of went over to donate. He's sort of taking over. He has the scissors. Yeah, And since college, Caroline, Let's go on. Richard. The student has become the master. Yeah, okay. Starfish he's doing at his old Isis dividing the adhesions we were talking about, and yeah, and you can see down here under his hand. This is all loops of of matted loops of small bow. And this up here is still scar tissue from his fistula that we have to somehow attack Peel the master. Yeah, You're still mesh under here. There you go. Yeah, You don't really know. 100%. you just get everything you possibly can. All you can do is all you can do that. That's too corny. Yeah, Everyone's nodding your head. Yes. Yeah. Maria. Yeah, yeah. Oh, for me, you learned so much as asserted for Resident that what you think is your most exciting brief is a good I'm in my third year, first year where I do major surgery operator first now, doing a lot food and accuracy. Really, Dr. Still a lot of really good and taking care of these rewarding, especially in my field of vascular, the sickest people in the hospital running back, especially Jurassic. You know, this conference of all we're not part, but vascular is like my secondary especially. And when you become a surgical technologist in a level one trauma center like Penn Presbyterian and you kind of have to learn every the video, just about everything Come on, brain, that's fine. The world. But it can be mhm. We'll never have to do that Yes, yes, yes, I'm We have tactic cardiac piece of rest. Like, so we just We kind of learned at all. Obviously, I don't need the level of knowledge. Is Sergent we work with? I have to, uh, yeah, I'll buy you on. But you get to learn a lot doing this. And if you're still not sure what you want to do, the search tech program is a good way to get in here. Then a lot of offer to go back and become a nurse or a doctor. Anything that sparks your interest from what you were. And I love every bit of what I get to have interesting is like, uh, can play a lot of fun a lot of, uh, okay, Got rock. Is my listening especially? Yeah. Every about. Keep my sanity up. Yeah, but then, you know, unique. You need doctors. You can come in thinking they know it to be a little intimidated, like, great surgeon and, you know, which is right. They're honestly, more intelligent. I don't know about that, but like, yeah, but, you know, I've sang Africa from soda with Dr Hart. Yeah. Oh, Oh, I forget. Yeah. Huh? Okay, I think my Yeah, it was a He was a wide eyed, So there's not a big rhyme or reason to what we're doing. Scholars. I mean, there is in general, but we're working at the top of the incision now, and and the patient's head is up this way, and then we go down below and we're sort of We're sort of just trying to pick the low hanging fruit, doing what's easy, the easiest and safest, and presents itself to us. That's the strategy. Yeah, that's my usual strategy. Life is hard enough. I want it easy. And I think that's most Yeah, weird. That's, I think, probably most surgeons. Yeah. This is This is, like cement with the blood supply. That's very, very tough scarred tissue. Which which Yeah, sorry. That was an attending move. I just pinched it and the scar tissue gave, um I guess that was a calculated risk. So it could have been, um, you know, I could have torn the bowel that way, so I'd stay way up here the first night we met because, right. Yeah. I mean, that's I get to do that move because I've been a surgeon for 30 years, and I've experienced doing it, and I thought I could do it. You know, all this stuff goes through my mind. Um, and I think it was hesitating and which he should at his point. Both of y'all. Yeah. Here. Yeah, I can. Right? So I've seen a lot of stuff. I I covered trauma at Temple for a long time. So I think I hope that any get in I can get us out of. And if I don't think that, then I would certainly I would just go free edge. Yeah. Free edge. Yeah, there's a famous There's a famous saying that, um no surgery residency for five or 7 years or even 10 years. Yes. Gets you ready to start learning surgery and that you really don't start learning surgery until you're out doing it yourself and dealing with everything yourself and that The 1st 10 years are learning how to operate. The next 10 years are learning when to operate, And the last 10 years are learning when not to operate. That's that's pretty. That's pretty corny. I'm just I'm just still learning how to operate, I think. Yeah, right. Uh, I liked when I was going to medical school. E r medicine was Yeah, really Just a very new, um, a discipline and er medicine is a three year residency now, and it's extremely, um, well attended. It's very popular for a number of reasons, because when you work in the e r, doctors work Shits, usually they work in eight or 12 hour shift, and then you go home. You're done. So it's very circumscribed, Like my life I wear. Well, I don't wear a deeper anymore there. They're like, so nineties. But, um, you know, I get called all the time and I'm on call every four night so I could get called in the middle of Go ahead. Yeah, you got it. But if you're an E r doctor, do your work each ship and you go home and you're done, And you can set up your life where you work 40 hours or 60 hours, or you work really hard for two weeks and then get two weeks off, set up your life however you want. So it's very popular who are, um, her lifestyle. Like if you are a big camper or a big hiker or no, you like voting, or you like to use any specific thing. You can certainly know that if we take this out, it's probably sure. Yeah, thanks. No, it is. So what we're talking about is we feel underneath, covered by tissue. You can go to that or cut it or whatever, but every So we're pretty much free all the way over. Yeah, I'll get that. Yeah, we can put a book here. Mm hmm. Bouquet the you guys were asking about foreign foreign objects. I mean, these He's, um uh, sponges. The green thing is radio opaque, meaning it will show up on an X ray. And they have a little, like, electronic homing thing on there, So well, put a wand over the Abdomen. B 30 closed, but I've taken a few instruments out. Like, you know, this is called a coker plant. Um, it's a It's a grabbing plant. Yeah. Dr. Coker was the same as Sergent in Switzerland, the famous for thyroid surgery. He won the Nobel Prize in, like, 1908 or something like that. I'm not sure on that date, but think this for a little, Um, that's it. Mhm. Uh, I just dropped Ah Coker, God, Yeah, Yeah. So far so good scholar, um, operations. So pretty. Well, I was a little intimidated by you all with this complex of an operation. Um, I didn't want anything bad to happen to the patient while I was on camera. What? And this this ring that you see here, that is the book Walter Attractor and Dr Book. Walter was a surgeon in a little town called Rattle Over Mont. Uh huh. And he was the only guy around. There's nobody to hold the retractor for him. So he invented it, called. It was a self retaining retractor, and he probably sold it to a big company and made a Brazilian dollars, and then they didn't have to do surgery anymore. I don't know that, but Okay, so if you can see in here. Here you go. So show him around a little bit. Mm hmm. This little. See this little guy? That's the appendix. All right. I got a little blood little bleeder debate that was from my And can I have a shoe knit sleep? That was from me being too rough like a silk top, right? Yes. In my yield to show you guys, the attendant. But it's not a big deal. So the appendix is at the bottom of the colon. This is this part beginning of the whole and which we call the Sikh. Um, And then Nick Coghlan goes up the right side of the patients body, takes a right hand turn and comes across the top that's called the transverse colon, and then takes another right hand turn and goes south and goes down now at the bottom. Yeah, it looks like a It looks like a big old question mark. And right now we're doing more adhesion. And here's that hole in the bow that we found. Yeah, the fish mouth. Very good. Thank you. These are these are adhesions in between loops of the intestine. So these are inter loop into adhesions. The big mass of adhesion here was stuck to his abdominal wall, and we're gonna have to free all of this stuff up. Um, before we Yeah, divide all those adhesions And what in the way we're doing right now? This is the small intestine, That's why. Yeah. Mm. No, I like to run. I mean, that's my my my sanity. You know, we stand here all day. I was a runner in college and I still like to run. Try to stay in shape. Yeah. All right. Go ahead. Yeah, I'm fine. It's my to go hiking. Really? Yeah. You got uh huh. Hard right for another woman. But I was going to try to get Nate to talk about is during residency, is demanding You have to work a lot. Um, the days can be long, but they have these things called work our limits in place to prevent people from working too much or present people like me from making people like Nate work too much to promote. Um, you know, self care. So in the old days, you know, now I sound really old. You know, um, I used to have to work every other night or stay over in the hospital, that is or, um, every third night. And it's not like that. Now, when you train to become a doctor, um, you're supposed to have one day, one full day off a week You're not supposed to were. If you are on call and stay overnight in the hospital, you get the next day off, and even so, it's still demanding, even with the work. Our limit? Uh, that's a great question. It's been studied pretty extensively, and it hasn't affected patient care. Um, and that's because residency now tends to be a little more. Um, we're gonna need some three year old belts on top. Tends to be more like a shift. Work like Made is supposed to go home at 6:00 tonight. And that means there's going to be a person coming At 6:00 tonight to cover tonight. And that's called a Nite bloat person. And so when the night float person comes, yeah, here's your pit shell. So Nate has to do this thing called a sign out. Yeah, that's good. Good, good, good. So he has to tell to the night person about all the page, and it's in those handoffs that we initially found, like things get missed and they dropped through the cracks, and all of you forgot to check the hemoglobin on this person because it wasn't signed out. But now I mean it. work hours have been enforced in place for a bunch of years, probably at least 10 years and people have gotten it pretty down. Pat like all the sign out in the communication and all, and it's been it's been studied. So a bunch of the old heads don't, you know, say, Oh, you know, when I was young, I worked, like, every other night. And the only disadvantage of that is I missed half the good stuff on my night off. Um, but we know that's not a healthy way to be, um, So all these old heads studied it, and they said, Oh, well, you know, this this, uh, let's get this down because we might even just take this whole mass out. We'll see. Yeah, So maybe don't need to waste are trying. Yeah. This fat here that I'm picking up is called the, um Ente Mu. The the right there. The momentum. All of us have fat inside our abdomen, no matter how thin you are. And that's called the momentum. The momentum in Latin means apron because it hangs down off of your colon and it covers your abdomen. Sketchy, too, that it does very good. Yeah, it's sort of like when you have appendicitis or any inflammation. All that fat sort of covers things, so it's good and bad because it increases adhesions, makes our adhesion removal more difficult. But it also helps protect things again. You guys, that there's not a rhyme or reason. It seems like we're just like calling at the bowel and, um, dividing stuff. But there actually is. We're going for a lot of the adhesions that are easy to do. An obvious, because again, we like to pick the low hanging fruit. Hi. So the main piece of mesh is out. We haven't decided yet. Whether we're taken out more. Here's his, uh, lot of small bowel. That was all this was that he used to his mesh on the inside. There's this fistula mhm right there. So we were trying. We're trying to get this read up enough so we can figure out if we can take all of even though this is a lot to take. Yeah, yeah, Usually especially after an operation is extensive in the abdomen, it takes the his bowel colon and the stomach and the GI tract. Um, A's. You start working again, and everything leads us all. What roads lead to Rome. Everything we do leaves us back to this badness. See how I'm making a Nate cut. Because if we cut into the valve, then I can blame them, right? Yeah. Mhm. Yes. You know it. You know it. These scholars or scholars for a reason. You're all going to do very well. Yeah, yeah, yeah. No ship? No. Okay. Every night. Exactly. Right. Yeah, yeah, yeah, right. Look at that. Oh, gosh. Is he good? So great question. So there's I'm just going to speak about surgery, because that's all I know, and I I I actually have a master's degree in education, medical education, and I've always been involved in training residents and medical students, so I get that question a lot. So a lot of it is thick What hits with you and your life and so geography and support system. And it doesn't matter for you guys right now, but love, you have a significant other plays, a huge role, I think, in where you train where you end up, etcetera, etcetera, and it should have a big role, but, um, additionally yeah. Additionally, you should go to an institution that bit with what you want to do with your potential plans. A lot of People come to 10 because Ken is very strong in pediatrics because we have chop, which is arguably the number one pediatric hospital in the world, not just the nation. Um, so that's a huge draw. People come here to do general surgery just so they can get into chop to do the pediatric surgeon. Yeah, Temple Hospital is in North Philadelphia, which is a very rough area and is very socio economically challenged. So there's a lot of trauma there, so people who are interested in trauma go to temple the train, because there's a lot of trauma. So a lot of it has to do with what you wanna do. Okay, guys, I'm gonna I'm gonna digress. So here's your colon again. Here's your transverse colon. Um, that's all. And he's the stomach is back there somewhere which we can't see. And this all is small intestine, which we're still working on. But where doing increasingly well. So it has to do also with, like, where you, um 10. Is I an Ivy League institution? It's a It's an elite institution. It actually depends. Surgery program was tied for 2nd in the United States, Harvard was number one, And Johns Hopkins and Ken were tied for # two. So you guys, if you're looking here, you can see a slight little line here, Uh, that small bell and that small bowel, and that's called an anastomosis. So he had had some of the bell taken out and hooked back up right in here. So that's the foul coming in, making a U turn and going out. And this We're starting to figure out what's been going on when you apply to medical school, just like applying to college, You apply to a bunch of medical schools. Um, you know, you apply to, uh, maybe a one or 2 Safeties. Um, most of them are realistic. You apply to a couple of reaches, and when you apply to a residency, actually the same thing looks like Drake, huh? So if you can look in here What I'm pulling up with my hand. It's called The Ligament of Traits. You want to get that traits T r E I t z. I don't know who treats was. I'm sorry off the top of my head, probably a German pathologist. That's like the standard answer, but that's that's the most proximal part of the small intestine. His stomach goes into the duodenum, which we haven't seen, which we may. I'll show it to you, then it comes out in the June. Um uh, approximately is the ligament of traits. So we are an heir soon anastomosis. And so now I'm doing a thing that's called running the bow. I'm starting approximately, and I'm working distantly. And we have freed this up enough right now, which which I'm really happy about that. We've got it figuring it out. Yeah, I think we have. Yeah. All right. So there's proximal. There's this big wad of momentum here that we see awesome. Yep, I know nothing. This is just a massive license of adhesions. This was just a handle on this big on this stuff. Then there's also programmes that you don't have to go somewhere like 10, um, hens. Very academic. Ah, there's community programs like you would train to be a community. Surgeons, um, work in a smaller hospital, fix hernias. Now 10 is a really big place. There's I think there's, like, 130 surgeons in our department. Stop. Yeah, you are. Temple had I think 40. So for a big academic center and I know. I bet you someplace You guys are up at ST John someplace like my monitor these or um, for now or n Y u uh, they probably have it on the order of hundreds, you know, over 100 Sergent. And this yellow stuff here is called the Mezzanine Terry. Um and that's where the blood supply of the bowel is comes from way down in the middle, where the aorta is and it supplies blood to being tested. And the mesen Terry in Latin means leaf. Because it looks like it actually looks like a long, uh, leak, if you will. Meaning page like a leaf of a book. Higher. Mhm. Yeah, well, all the blood supply goes to your bow if you eat. And that's why people get tired at, like, postprandial like you need a nap in the afternoon if he lunch and stuff. Really? Oh, yeah. Yeah. So, uh, there's a There's a famous, uh, you know, there's there's a Philadelphia taco as well. Philadelphia tacos. So if you go to this famous cheesesteak place called Jim's Steaks and it's down on South Street, yeah, yeah, yeah. So, like to two doors away, there's the famous pizza shop and their pizza is like a quarter pie. So if you take your tooth steak and you wrap it in a slice of pizza and then you eat it, that's a Philly taco from over a year. Mhm. Okay, I have not. Right. My son has no James is a good place. Mhm. I've had gyms, and I've had the Aransas. But when I learned about the silly talk decided to be strict to my team moving through the diet. So I had to watch all my friends eat the silly taco. Well, I just eight and pride, okay? Oh, yeah. I mean, I was probably, you know, watering at the mouth at the same time. How they were after eating this. Not so. I didn't want that. We're going to live there. Yeah, back. Yeah, we're still doing, uh, he's the lice ist and no, we still have freed up all of these. We still have these loops all here to figure out with the boat. We actually put a return head on the patient's leg on community service on the you will, Actually, nice, please. Yeah. Night, please. If you got if you got a 15. Yeah. So it actually will divert the action into the ground and parent in back to the machine so that the courage of your body, especially when you see we're using a lot of metal objects. If we didn't have that return path the electrical part through the body to any of these metals instruments and actually burn the page, And you you could see that, uh, have it for yourself. So yeah, you know, you're not in it. Oh, God. You got it. So this is so close. I just did it with a knife and there's a little bleeder there which we're going to show up. So even though we're taking all of this down scholars, all of this will never be able to get all of this scar off, so we'll wash everything out, and we'll put this back in Well, actually put a momentum over it as best we can, but I think the risk that he could develop another fistula is significant is probably about, I would say, 10% to 15% like one out of 10-1 out of seven chances. And that's because of just a bowel injury. Um, would do anything with that, you know, Uh, yeah. Um, and there's nothing like I said earlier. All we can do is all we can do. Um, yeah. 70. Yeah. So I think we and where does it come up? Hospital. So we're trying to figure out what the heck's going on here. Um, here's let's go back to the beginning Ligament of traits. And that's the Moses. And that's scarred. Okay, we'll keep going, and then we'll go into this really big scar here, and we might just take all of this out. And that's his fistula right in there. That's the whole See my fingers inside the bow. Okay, You might take all of that out and then hook up the bow to itself, okay? And that would be an anastomosis. And what I wanted to do before we pull the trigger on that is Oh, yeah. Oh, yeah. So we're almost at the point where we're actually going to do this Operation dollars, Right? Right. Oh, mhm, right? Yeah. My wife often, right? Yeah. So though the electrical current comes through here at the tip, patient has a big sticker on their leg, and the current goes through the patient and completes the circuit to the machine. I'm wearing rubber gloves so I can touch myself and not be burned. Right. Um, if I were to, uh, grab the tissue and touch me the electricity, you can see it. Smoke will go through again to the patient. Yeah, yeah, yeah. Um And then So that's how the ability works. And then what was the other question? Yeah, so fistula. In general, any fistula is an abnormal connection between something and something else. And we say that a lot in medicine because then we characterize it. We say, Oh, this isn't entero cutaneous fistula, meaning officially between an abnormal fistula between the bowel and the skin. So that means there's a hole in the somewhere in the bow which was leaking into the abdominal cavity and causing an infection, and then involved the mesh because it's probably the mesh caused it and then was leaking, you know? Sorry. Sorry to sorry to use profanity, but there's an old saying that 5th and Puss must come out. So the past, the infection? Um, yeah. So if you guys can see down here, can I have a four step? I'm holding the, uh, the small bowel here, this little piece of fat. It's called The Ligaments of Trees T R i e. And that's the far end of the bow right before it dumps into the colon. And here's the appendix again that I showed you guys earlier. So we have found I'm pretty proud of. I'm like a proud father with Nate right now, because we have we have found the empire. We have freed up the entire, uh, small about which is no small thing. And you guys saw it. And I I thought the world made my last day working with him, too, So I would take this as a just a natural. So here's the fish shell of guys and all of this nastiness, and we're gonna use the stapler now. And I have a blue G i a blue. So we're gonna divide this and take it out. Do we use a leggy an 80 fleet? We use a leggy too. I think the students will love it. God, we got Yeah, I would I would just close. Yeah, mhm willing for so scholars, if you can see this thing, that's crazy looking thing is a stapler. Um, and this blue part is that's the anvil, and that's where the staples are. And when we crank this down, it's going to put down four rows of staples and actually cut in between. That's actually the night. It's plastic sharp plastic, and it's called a G a r a gastrointestinal stapler. Staplers were invented in Russia in the 1950s because after World War II, um, all of their technology and science and actually, men uh, yeah, go ahead were decimated. And so they invented staplers that could be easily reproduced and used with little train. And there's the two ends that we just stapled and divided. And back then it was the Cold War, and there was a famous surgeon who's actually from Pittsburgh, who got to visit Moscow, And he actually stole a bunch of staplers in the 1960s and brought him back. Uh, now it's a multibillion dollar industry. Um, that these Ethicon and all these companies, uh, sell staplers. Yeah, yeah, No dumb question. No, it's it's made. I think it's made by Ethicon. Yeah, yeah, yeah, yeah! And there's all kinds of different ones with different sides, staples and different lengths here Dr. Shanmugam uses exclusively. We're probably gonna so this bowel, together with the traditional I'm an old dude. So I like to do hand soon because that's part of the fun of surgery. So we have excluded this. Here's where we'll so things back together right in there, as you see. But now we have this Lod of nasty Bow. It's still attached to the mezzanine, Terry. So it's still a blood supply. This thing gun looking thing is called the Liga shore. So it grabs the tissue, feels it shut with heat and then cuts it. Mhm. Yeah, it's just It's faster and easier. We could plant it and tie it. That's sort of like the traditional way. Okay. one of the top. Yeah. Yeah, you're right. Yeah, that's called. It's called an e. A end to end anastomosis. And it's a circular stapler. Yeah, Yeah, right. Connects the two ends. We're gonna we're gonna connect the two ends side to side, which is another very standard way to connect Val. That way we can make it a really big opening, and it's going to actually look like the one I showed you, which was done years ago. we're gonna need three popped 3 to 3 fights. And there's the respected Val, if you guys can on a pier. Good a pistola. Yeah, You have. Most people have, like, 20, ft of small bow, and you can get along with about I would say three or 4 at the lower end. The lower the lower limit like below. Now you're gonna not absorb your nutrition is going to be a big problem. Yeah, yeah, yeah, yeah. Rio feels like Okay, How would you still Yeah. Yeah. So you wanna hamstring me as much as possible. So I would start way out here and then go like that to you. I don't know if we've ever done a hand soon before, so I start towards me and I don't go. Here. Here, here, here, here. Is that I think that rolls it in. Okay with me on that? Yeah. So the traditional way we are putting about pig back together as you can get more than one out of this. That's fine. Um, I could be wrong, but I personally think that residents like doing it this old fashioned way. It takes a little longer. Um, but it's doing stuff. It's like why people go into surgery to do stuff. Use that, please. Yeah, and this is his last day. So this is like my president, my surgical son. Here. No. Put on some Michael Jackson music. Just I'm just kidding around. Mhm. Yeah. Okay. Yeah. So what we're gonna do, guys, you saw the meat of the operation, and now we're gonna where you can see, we're sewing one side of the bow to the other, and there's the two stapled end one side to the other, and we're gonna make a hole here and a hole here, and we're actually gonna put another layer of future in. So the two holes go like that, and then we're gonna put another layer in the top, and then we're going to be done. We're gonna irrigate, and we're going to close, and we're not gonna use any mesh. Go ahead. Um, so you saw the meat of the operation, and and like, in a lot of operations, like We didn't 100% know what we were gonna do going into it, um, so hopefully saw like, um, Nate and I sort of talk our way through this and talk about what we were finding and what we should do, and that's that's very prominent. A lot of operations, you sort of. We're not making it up as we go along, but We're not 100% sure of what we find. And we we react to what we, um what we find in the operation and we do as part of what's called clinical judgment and surgical judgment is we do what we think is best and safest for the patient will give us the best outcome. Do you find out? Yeah. Mhm. Yeah, absolutely. And that's part of why I mean my my entire career, I've worked with residents. I've never been in private practice. And, you know, I love shortening everything I love having younger, bright people like to bounce stuff off of. I mean, he has an understanding of the literature, um, from his point of view, and I have a point of view and, you know, we we all talk And, uh, yeah, and if there's any anything you know, an aesthetically like this person's blood pressure was low. The anesthesia guys we would be talking to if there was like an issue with the leg ashore or the staplers. I mean, I'd be working with Max, and that should be talking to the circulating nurses who are behind the cameras that you haven't seen in order to, you know, hopefully do what's best for the patient. Mhm. Shoulders back. Yeah. Yeah. Mm. Mhm. Yeah, Very good. This is this is silk. We're using its permanent future. They're interrupted and silk is permanent. The dung of the worm. You call it, um, we could use plastic, but generally you want to do more. Okay. No, that's good. Pinch that. I'm talking and not paying attention to what needs doing the next. No. Um, no, I am paying attention, but so these actually now our handle Former. Okay, so I go here to Here you go. So now we're making holes in the bowel. You guys are still there and watching. Go back right now? Yep. Mhm. Mhm. Yeah. You mean do some sort of, like, cosmetic procedure? Yeah. Okay. Uh, yeah. Sometimes you take, you know, stay quiet. Yeah, the question you guys would. Yeah, Yeah. Um, you could I think the only other method is, um uh doing nothing. Sometimes his shows will close on their own. And I completely agree with you. Oh, scholar, that no surgery is better than invasive surgery. But surgery is sometimes is necessary. If I had the choice of having a fistula. And so you see a hole here, guys, and you see a hole here That was a little smaller. Yeah, more. And that's essentially poop on the inside. Not essentially. It is like a dirty bucket. Keep them print out just because everything Max Sano his or that's yeah, Yeah, that's what it normally looks like. Kenya et filii taco and goes through Mm, yes, Yeah. Full thickness. Yeah. Yep, yep. Run it. Or Rio on a non cutter. We need two of them. Yeah, we run. Run around. So we did. We did the back half of the outside of the anastomosis with permanent future. That's the strength player which holds it together. And then now we're going to use absorbable future for the waterproof layer. The ceiling s e a l, uh, layer. And that is a running layer all the way around. We call it the Hema static layer, which will prevent it from leaking. And then we'll finish up by putting the anterior layer on and then we'll be done. Yeah. What? Really? Okay. Have a great Mary work. Sure, man, This is really fun. Take another one. You can cover that. All right. See you, guys. Good luck to all. If you wanna somehow given my email address, you certainly can. Or if you haven't already Yeah, right next to each other. All right. Yeah. Was I too smarmy? Thanks. Uh huh. Created by Related Presenters Sean Harbison, MD Professor of Clinical Surgery Gastrointestinal Surgery
