The Hernia Gods Podcast E15 - Edward Felix, MD FACS

Episode 15 of The Hernia Gods Podcast features a legendary conversation with Edward Felix, MD FACS where he discusses the origins of The Ten Commandments of the Myopectineal Orifice, his experience as one of the fist high volume laparoscopic cholecystectomy surgeons, and his opinion on the abandon the sac technique of inguinal hernia repair.

Disclaimer: The views, thoughts, and opinions expressed on this podcast belong solely to the hosts and guests, and do not serve as a representation of or necessarily reflect the official policy, position, or opinions of Orlando Health or any of our employers.

Transcript

SPEAKER_03 0:06

Welcome to the Hernia Gods Podcast. This is your Mere Mortal host, Luke Helms. The views, thoughts, and opinions expressed on this podcast belong solely to the hosts and guests and do not necessarily reflect the official policy, position, or opinions of Orlando Health or any of our employers. And now, without further ado, let's talk hernias. All right, hello, and welcome to another episode of the Hernia Gods Podcast. This is your mere mortal host, Luke Elms. Today I am very pleased to be joined by Dr. Edward Felix. Thank you so much for joining us, sir.

SPEAKER_02 0:39

It's my honor. I'm I'm just surprised you still want to have an old retired guy like me around.

SPEAKER_03 0:46

Uh well, you know, I I was gonna say, you know, it's um your Ten Commandments, you know, it's one of the main pimp questions I ask my residents. And so whenever whenever I told one of the residents I was working with recently that we were having a conversation, uh his mind was blown. So you're you're still very relevant, at least around these parts of the woods.

SPEAKER_02 1:05

Well, thank you. And I'll I'll I'll tell you how we got to 10 somewhere in this uh podcast because it that's a kind of funny story.

SPEAKER_03 1:13

Absolutely. Well, I'd love to start just by hearing, you know, a little bit about you know who you are, where you come from, and kind of your career.

SPEAKER_02 1:20

Yeah, I was I was born in Chicago and uh went to school there, then went off uh to the University of Michigan, and I'll hold up my uh bleed blue sweatshirt because once you go to Michigan, you bleed blue for the rest of your life. So uh, and that's how I spent my Saturdays is watching uh Michigan football. So, but uh went off to Michigan for uh undergrad, and then because I was paying for my own medical school, uh I went back to Chicago and picked the school that gave me a full scholarship, which was the University of Illinois, and went there for four years. Interestingly enough, I went to medical school with the idea of becoming a psychiatrist and not a surgeon. Uh and I matched in a psychiatry residency with my ex-roommate. We both matched. And three days before the residency was supposed to start, I said, this is insane. I cannot be a psychiatrist. I had worked as an OR tech at Rush St. Luke's, which was part of our system back then, before it became its own med school. Uh, and I said, I want to be a surgeon. This is this is crazy. I don't want to be a psychiatrist. So I went up to Dr. or Professor Nius's office, and I knew him from the AOA society. And I said, What am I to do? I I I didn't, I'm matched to psychiatry and I want to be a surgeon. And he said, Fine, I'll make you a spot. And he actually did. He added me on because he knew me from the society. He knew what knew my credentials. He added me on, and I became a surgeon under him. And then I was very, very fortunate during that training. Uh I met someone named Tapasta Skupta, who's a famous surgical oncologist, who took me under his wing, uh, got me a position at the NIH for two years, which was unusual for a Midwestern kid, uh, and did that instead of going to Vietnam, which was somewhat safer than Vietnam, but not quite. But spent two years in D.C., went back, finished my uh residency at the University of Illinois under Nihoos, stayed there as a as a prof for a couple years, uh, ran the Cook County Oncology Unit, actually, uh, and then went to California uh to do uh private practice. I got tired of academics. And the interesting thing, and I and I've said this before, is before I left, uh Professor Niuse said to me that I could do something beyond private practice. He said there was a guy named McVay, who I'm sure you know who that is, who was nothing but a Midwestern surgeon who became very famous and very academically oriented. And he said that to me, and I was in his office, and I was being very polite. And I said basically, nah, I okay, Dr. Deus, you're probably right. And I knew at the time that was never going to happen. And I went off to California, uh, landed in Fresno, and I don't know if you know anything about Fresno, but it's sort of like your hometown in Oklahoma. Uh Fresno is a small town. I did surgical lank there for uh for 10 years. And then uh someone walked into my office one day. I was covering for my partners, and I did general surgery, but not that much. And I did vascular and general, and she said, I saw something on TV last night. Uh, and you're supposed to take out my gallbladder. Can you do it the way they did on TV? And I said, What are you talking about? She says, Yeah, these guys did it with these little sticks and little incisions. And I looked at it and I said, come on. So I ran home, I turned on CNN, and there's my buddy Eddie Reddick, uh, who later became close friends with me, uh, doing the first Cole's, supposedly the first Cole's. And he really wasn't, McKernan really was. Uh, and and I said, you know, if I was to do that, I bet you I could be quite successful. And so I came back, I came back to Fresno, met up with Joe Petland, and I don't know if you know that name, but Joe taught me what to do. And then that was the beginning of uh a new career. And probably I did somewhere in the first year around 500 to 1,000 gallbladders. Uh, because I was the, if you know the history of Lap Cole at all, very few people accepted it. Nobody accepted it at the academic institutions. Uh and so I I took off with it and was doing them like crazy. Ended up teaching with the guys from Cedars down in LA. Uh, we ran courses and taught, and and I had done basically a couple thousand gallbladders. And and then I heard about a guy named Leonard Schultz, which you don't know that name, but Leonard Schultz was a uh guy in Minnesota who was trying to figure out how to do hernias laparoscopically. And I said, you know, I bet you I could do that because Nihu's taught us how to do posterior hernia repairs open. And so I came back to, I went off and met up with a couple people and then came back to California and just we gathered some patients, my partner and I, and we said, told them, well, we know how to do this posteriorly open, and we're gonna do it with laparoscopic instruments. And uh the patient said, You sure? And we said, Yeah, don't worry about it. We had no rules or anything, and I found a surgery center that would let me do it, and that's how it all started. Uh, but the difference, and here's the key difference, is that when I did all the collisions, I didn't keep any records uh on a computer. So I ran out uh and bought a Dell computer, my first computer cost me, and I still remember, cost me seven grand for that for that Dell computer. I should have bought Dell Stock because it would have been seven grand would have been worth several million. Next thing I bought the computer. Uh, and I kept a database, and that was the beginning of uh lap hernia for me. Uh and we collected uh, I think it was the first 500 cases I collected. I presented at the American College of Surgeons. And then someone said to me, Well, you can't be doing all those hernias, you're not a hernia center. And I said, Oh, that makes sense. So I came back to California after being in Chicago for the meeting. I said to my partner, we're now the Center for Hernia Repair in Fresner, California. And and and I just started collecting data and and experimenting and and refining the technique and uh and the rest was history. We did, you know, I did somewhere between five and ten thousand lap hernias and and collected the data and started writing papers and became what Nihoos predicted was uh academically oriented. So that went on went on for a number of years. And uh if I'm not being too winded, I got bored. So I decided I needed something more complicated. So I because I was doing other minimally invasive procedures, so I started doing bariatrics then, in addition to hernia, and did that for another 10 years. And that's uh that's for another another podcast, but uh it did a lot of writing, and that's how it all came about uh with the lap hernia. Uh how did you do the first few?

SPEAKER_03 8:36

What was your technique on the on the first few? What was like the approach?

SPEAKER_02 8:40

Yeah, it was interesting. If you look at our original papers, uh Dr. Nihoosa developed something he called the the buttress technique for his for the open uh posterior repair. And so I came up with a slit with a with a slit around there, but then I decided that that slit was potentially a place where you could herniate through. So I put another small patch over the slit and called it a double buttress after nihoose because I knew it would make him happy. Called it the double buttress technique. And we did I did somewhere around a hundred plus cases of those. And it was way too much mesh, but I can tell you it it was bulletproof. That that thing almost I think out of out of the first hundred I did, I did one, I had one documented recurrence. I mean, there's just nowhere it was going to recur, but it was too much, too much mesh. Uh and and that w that shifted you just to a non eventually a non-slitted mesh. Uh and we I did probably 500 to 1,000 of those. And then a company called Origin. I don't know if you know about them. Origin was the company with Fred Maul, who actually invented the uh the intuitive computer, computer robot. Fred Maul had this company called Origin, and he was trying to develop an extra peritoneal technique. And he he and his buddies flew down to Fresno because they heard I was doing all these cases, and they couldn't believe some little old guy was doing that in Fresno. Uh and he said, Would you like try to do, would you like to do this? And I had already kind of run out of things to write about, very honestly, with uh a posterior just tap approach. And so I said, Okay, well, we'll we'll see what we can do. And then I started doing extraparate nail or TEP and named it the TEP TEP uh because I thought it sounded cool with TAP TEP. That's how the name, that's the name TEP came about, very honestly. It was some people had named it something else, but I call it TEP. Uh and so then switched over when I saw the advantages of the TEP approach, switched over to a TEP uh repair and then slowly modified it through the years. Uh and that's we can talk more about that, but but basically switched and felt that the TEP for most cases, not all, but most cases is a better approach than a tap approach because you don't violate the peritoneal cavity. And then of interest is Neo's, you have to understand, he's really but with SOPA the father of a posterior repair. But he thought laparoscopy was crazy. He was very much against laparoscopic hernia repair. Uh and in fact, he had attacked once Bob Fitzgibbons, who's another from Creighton, about it, and and he was very unhappy. So a debate was set up at the Marin College of Surgeons. I had a debate, Dr. Nihoos, on laparoscopic hernia repair versus open. And so I presented the TEP to him, and at that meeting, he was won over and started supporting because he felt there was no reason you should violate the perineal perineal cavity. So that's enough of the history.

SPEAKER_03 12:05

So you and so after you worked out your technique on the TEP, did you was that your standard approach moving forward?

SPEAKER_02 12:14

Yeah, I uh the TEP was a standard approach, uh, except for uh if someone had an incarcerated hernia that I couldn't reduce, I I think tap's a better approach. Uh if you have a female and you don't know the etiology, if the pain is due to the hernia or something else, you want to do a tap. And if someone's had a previous posterior mesh repair, uh I've written some papers that I think taps a better approach. I don't like to go back tap. There are surgeons who will go back tap on a on a recurrent hernia with a posterior mesh. And I think that the risk is greater, and I've debated that. I think the risk is greater than the value uh for that. So those are the cases that I would do would do a tap. And now that robotics has come about, it's kind of flip-flopped, but everybody's doing our taps. But there are a few people, and I and I give them credit, and uh Flavio Malcher and a few others who have come up with a robotic TEP. And so I think it's a dip more difficult, but I think that will become the approach because you can combine the hernia repair with a with the ETEP uh ventral hernia repair all as one. So I think that that's gonna gather steam.

SPEAKER_03 13:31

Yeah, I've done a few of those. They work well. Uh you have to you have to make sure that you get your I think it's it's for me, you know, something I was aware of prior to going in there uh and and doing those was always thinking, don't skimp on the dissection of the inguinal hernia, because I think that's like the natural, the natural tendency is to be like, oh, you know, that's you know, but really getting everything back like you normally would and just making sure that you do a good quality repair down there, too. But like the patients I've done that on where they've been they've been really pleased.

SPEAKER_02 14:02

Yeah, I and I think my buddy Jorge has been the one who's kind of brought that uh uh you know with some others to the forefront. Uh but I think it's if you can do that with a ventral, there's no reason you can't do that just as a primary uh robotic repair if you're into robotics. Uh that's a whole nother debate whether robotics is better. And and I've kind of swung around uh and I we can go into that a little bit, but but I've debated your buddy Conrad uh multiple times. We had a we had a fun time because we're very best friends of making fun of each other. Uh but uh you know I I think it's swinging the robotics, but that's okay. Uh as long as it's done minimally invasive. And I think if you look at the numbers now, uh there are more hernia's done minimally invasively if you add robotic and laparoscopic than open now. And so I think that that it only for me, it only took 30 years to get to get that to get that to happen.

SPEAKER_03 15:04

Yeah. Yeah, we um I I started my career doing um I started my career actually doing tips. Um, and that was and that was kind of how I was I was trained to do the minimally invasive. But really, honestly, when I came out of my training, I always felt and still do that I needed to be able to do everything that I do laparoscopically or robotically open, because ultimately, if you get in a situation where you have to convert and do a different approach, you gotta be well skilled. And so I had a a partner who was yeah in his mid-70s and he did all open. And so I actually took took some cues from him and really got comfortable doing some of the open, open ones. And and at that time, I was also doing a lot. I my whole career I've got a lot of inguinal scrottles, and I don't really know why. It's just that's just what shows up. And so I was at that point, I was not doing yeah, I wasn't doing robotics. I was doing, and I did not approach, I wasn't approaching those minimally invasive. I was not comfortable enough in that in that technique. But then when I when I switched over to robotics, I still will occasionally do a uh a laparoscopic, but mostly now that's that's just what works for me. And and I've definitely noted that even my robotic approach has become much more refined. I think the the reps really make a difference for me.

SPEAKER_02 16:23

Yeah, I well, it's it's repetition over and over. I told someone the other day uh I was talking to uh a surgeon, one of the bariatric surgeons, and and what's the difference between an expert and a novice? And the difference is an expert has made all the mistakes already, and so they have that to go back on and say, well, I know, you know, don't want to do that, or or or I know how to fix that. And that and that's partly, you know, you talked about the Ten Commandments. That's partly how the Ten Commandments came about, uh, actually, uh in my original lecture is is is something that was the impetus for it. Uh actually.

SPEAKER_03 17:06

Yeah, that was actually my next question, which is you know, you can learn lessons or come up with techniques, or but really life kind of teaches you lessons, and some of those lessons are learned through success and repeating and repetitive success. And some of them come from failures. The Ten Commandments, did those uh were those from success or failure mostly?

SPEAKER_02 17:25

Well, I can honestly, it's a combination. The it they they came. I I I was at a meeting watching uh some uh one of the national meetings, and I was watching some videos as I walk as you do as you walk around the booths, the commercial booths, not the not the meeting meeting, but the commercial booths. And I was watching these people operate, especially in the early days of robotics, and I was seeing stuff that just didn't make sense. I mean, we we had been I had been doing this now, I say started doing lap hernia in uh in what was it in in night in 901, 1991 was was the year I think we started I started doing lapurnia and I started doing Colees in 90 and about late 90s, early 91, started doing lapernia. And we had years and years of experience of as you say, seeing what worked and didn't work. And I was watching these guys do stuff that we had abandoned 20 years ago, that this is not what you should do. And we had written about it, and I said, This is crazy. That there's certain steps that you need to do. So I I had to give a lecture actually at one of at one of uh uh uh the meeting, ski meetings uh uh with uh from Columbia, and and I said came up with this idea. I'm gonna I'm gonna present the steps of what you're supposed to be doing to correct this from our experience, uh and and not uh what you know, not the errors, but what you have to do in each step to try and prevent these errors that I was seeing, these crazy things that people were reinventing. And I came up with nine rules. Okay. And I said, nine. I these are these are and someone said to me, Well, though, what are those? Are your commandments? I said, Yeah, these are my commandments. I said, Well, if you have commandments, you have to have ten, right? Yeah, I mean, everybody knows, everybody knows that. It doesn't matter whether you're Jewish like I am or Christian, there's ten commandments. You gotta, yeah, there's not nine. So I I I was at a meeting and and I said, Okay, I got the idea. The tenth commandment is no matter how you do this repair, TEP, TAP, ETEP, robotics, you have to follow the first nine. So that's actually the that's actually the 10th, 10th commandment.

SPEAKER_03 19:53

That's funny. You think that do you think the 10th commandment knows that it was an afterthought? I just imagine like the 10 commandments, like children. This one's like doesn't realize it's like, how's the mistake?

SPEAKER_02 20:02

Okay. If if you come, I'm I'm gonna show a video that I that I've made and and gotten partly from somebody else, but a video it this year's coming up in uh in uh August at the American Hernia Society. I'm gonna start out my session with with with a video that shows how the 10 commandments came about. So I'm not gonna give it away here. I've shown it before, but you'll you'll have to come to that meeting to see that. So I don't know. I think the 10th commandment doesn't care, doesn't care uh what's going on. But but then what happened after the after I did these Ten Commandments and gave the lecture a few times, uh Jorge Dayas, who's uh I've known now since he attended one of my lectures way back when in the bad days, uh we become friends, and he said, you know, we should we should publish this. And I said, Oh, you who wants to who wants to listen to this garbage? And so uh he and I got together and he started it, and then we refined it into the nine steps of the critical view, which actually came from uh Brian Jacobs, the International Hernan Society uh collaboration. Uh so we took those nine steps and and defined them, and then he sent it off to the annals of surgery, and lo and behold, it became the most downloaded uh paper from the annals of surgery, almost in the history of the annals of surgery. It has become you know, we we never dreamed of it, but it's become extremely popular because, as you say, it's a way for people learning to do it, how to do it, and what they have to do to complete it. And it's also a way that some people have told me that when they get done, they went, Oh, I forgot step six. I didn't take out the lipoma or I didn't do this. So it it's it's just a way, it's sort of like A pilot who has to go through the checklist. And so that's, I think that's why it became popular. Then there's been one variation. My friends in Brazil, um uh Malcher and and his Brazilian buddies, who still are still off in Brazil, came to me and they wanted to combine their approach with the steps. And we wrote a paper on that. And what that paper shows is that you don't have to start like we do uh on the medial side. You can start from lateral to medial and you can vary the approach by the zones and so on. So it's become quite popular. It's been it's been nice for me in my old age. It's been like a rebirth uh uh uh of my interest in hernia.

SPEAKER_03 22:42

Yeah.

SPEAKER_02 22:42

So it's been it's been it's been fun.

SPEAKER_03 22:45

It's like one of you have this for, you know, in the hernia world, it's probably one of the most questioned topics for residents. I know it is in my OR, so it's it's always funny. The uh everybody's like, he's gonna ask us about those Ten Commandments. But we um, you know, I think that the hernias, it's nice because having those in your back pocket, despite the crazy anatomy that some of these people come in with from their hernias. And if you can kind of stick to the if you can stick to accomplishing those set goals, you can kind you can kind of get there. And um it's it's whenever you end up in a you can watch people do and you watch people do dissections and and they go, you just kind of can get lost. I know that's the way I was when I first started. You're you get into those big ingredients scrolls, and you're just kind of like, where am I? Like, what is happening? But over time, you know, following those and kind of getting step-by-step approach, it makes it much much more manageable than if you're just like, I I just need to open the peritoneum and get the sack back, you know, and that's just a very broad approach. But one of the things I've seen a lot in my just watching other surgeons and and through training and things is a lot of people I don't when they're doing TEPS specifically, I think there's a I've seen a lot of people really not get nearly the dissection plane that that you really talk about. And also I think there's a tendency to use much smaller pieces of mesh because that. And so, yeah, I think that that's been that's been one of my observations, and that's one of the reasons I switched over is I felt like I wasn't getting as good of a dissection plane just because I hadn't done as many.

SPEAKER_02 24:26

Yeah, that I mean, that's exactly one of the things that we came to and and why why we wrote this is one of the things we saw at the college meeting, uh, is that people were doing tiny little dissections and then throwing in this micro mesh. Uh, and the and the important thing to understand is whether you do a tap or a tap, the finished product or the critical view is the same. Uh I don't know if you know any uh literature, but when I I I was a big uh reader of existentialism, uh and I what I feel and I've written about is that that the commandments or the steps, it's not the final view, it's it's the steps and the approach to get to that view. In existentialism, what you believe in is it's the it's the journey that's important. And I think that that's what's important in the hernia repair or in other in other things too, whether you're doing bariatrics, it's it's it's not just it's that journey of how you get there. And you're exactly right. You see these people putting in these postage stamp stuff, and and and some of my best talks have been going on the internet and pirating people's what they think are great videos. I mean, I have one one lecture that's nothing but but but pirated videos from the lit from the literature from the YouTube uh and use those to show this is what you're not supposed to do. Yeah, but yet the guy who put it up there, he thought it was it was uh the best thing in the whole world. It was sliced bread. It was it was great, man.

SPEAKER_03 25:59

Yeah, that's why you'll never see my videos online.

SPEAKER_02 26:02

Well, I'll I'll watch for them. But uh but it is it is interesting. If you if you want to find some some bad stuff to show your residents, just go online uh and and sort through people's uh what they think is is the right approach. Uh or you know, they come up with crazy things.

SPEAKER_03 26:21

But uh Especially for I went in to do a uh I went in to do a left-sided primary herny and the and the guy told me he'd had it looked like he had had a previous tap, a lap tap. And I go in there, and so I didn't, it was a straightforward case, so I didn't get pre-op imaging. But I get in and um look down in the right pelvis, and there looks like it was a piece of old, I don't know, dual, it was an old uh coated mesh that somebody had not dissected the peritoneum at all. They'd taken basically like an IPOM mesh, stuck it down in the right pelvis, and taken a metal tacker and gone completely circumferentially. So, like on either side of the iliac vessels, there's two metal tacks sticking, like one in the psoas. And uh it it didn't recur at all. I don't, I was I I was in there with the resident. I said, don't ever do this, but it seems to have worked. The guy didn't have any pals. I was like 99% of the time, that's gonna be a problem. This one got away with it, but don't do that.

SPEAKER_02 27:19

You know, that was an original approach. There if if if you know what if you know hearing a history, which I unfortunately know too much about now from from from my experience, is that was one of the original approaches. That was the approach of Bob Fitzgibbons uh to do an online mesh. And and uh the only person that sort of did that but but did it correctly was a guy named Morris Franklin. Do you know Morris Franklin's name? If not, if not, you Morris unfortunately has passed away. But you should Google Morris, Dr. Morris Franklin from San Antonio, Texas. He is the father, he he the the IPOM plus for ventral hernias, he is the father of that long before it was accepted. He's the father of laparoscopic colon surgery. I mean, he he was an amazing guy, but he would do an approach where it was sort of an IPOM for the inguinal, but he would actually dissect everything out and then just and then put it on. So it it was a hybrid kind of approach uh that some of us have to do when there isn't enough peritoneum, but that's what he would do. Yeah, but yeah, what you're describing as an old approach.

SPEAKER_03 28:33

Yeah, it was it was funny though, because the the residents were like, what is that? And I was like, Well, that's not something we do anymore, but yeah, it's hard to. I mean, for this patient it worked, I guess. Um, but yeah, so you know, you're talking about you went through a period of time where it was first it was gallbladders and then it was hernias, and it sounds like then from our discussions, you also moved into the bariatric world. And we're really kind of on the forefront of all of all three is pushing pushing the boundaries. And as you said before, it's really it's taken only 30 years to um uh to get kind of widespread acceptance to where people are coming back and saying, like, you know, this guy's this guy had it and he knows it, you know, and that he was he was right. During that period of time, is is there like is it you're talking about existentialism, is there kind of a uh early in that journey, are you were you ever sitting there going, did you ever feel like you were under siege, I guess is my question. Or or how did how does that strike you?

SPEAKER_02 29:28

Yeah, I was uh I was more than under siege. Uh there there's a famous lecture that I gave at the American College of Surgeons. It's only famous now, it wasn't famous then. But I gave got up there and presented you know, X number of cases to this huge auditorium, and people basically from the audience were swearing at me and said, Oh, this is stupid. You can't be doing this laparoscopically. And and I got I had just bought a baseball hat, uh, and I can't remember what city we were in, but I bought a baseball hat from the local team or whatever it was, and I was in a bag sitting on the floor. Uh and I'm from Chicago, and we got a lot of gangsters in Chicago, right? So I said, So here I am at a national meeting sitting up by there on the podium giving this lecture. Uh and and so I reached down to the bag, I pull out my baseball hat, I put it on backwards, and and said, Okay, here's the truth. Do you just believe it or not? And the person sitting in the audience that got stimulated by that was Jorge Dyas. And that's how we became friends to this day, as he came up to me afterwards and said, you know, you you're probably right. I should, you know, start doing that, and and and took off with it. But but yeah, no, people threw rotten tomatoes at me for years. The most gratifying thing I can say is something recent that's happened. The uh European Hernia Society, you know, they have all their rules and their uh what they say is proper to do, and so on, from thousands of cases. They have recently come out and said one, that the preferred technique for hernia is laparoscopic, whether it's bilateral or unilateral. That's something I said 30 years ago and no one believed me. They they tried to say it, you can only do laparoscopic for bilateral hernias.

SPEAKER_00 31:31

Right.

SPEAKER_02 31:31

And I said, Well, that makes no sense because if you can't do it on one side successfully, how the hell are you gonna learn to do it on two sides?

SPEAKER_00 31:40

Right.

SPEAKER_02 31:41

And then they said, Oh, you can only do it for recurrent hernias. That was the second thing that they originally said. There's no reason you should do them open. And if you want to do a laparoscopic, it should be for a recurrent hernia, if it's unilateral. And then again, I said that made even less sense because if you couldn't figure out how to do a primary hernia, how the hell are you gonna learn to do a recurrent hernia? Right. Well, the European Society, and then the final one was I said women should have laparoscopic repairs because of the incidence of femoral hernias, even when they present with an indirect and so on. And so finally, the European Society and in their rules this year have come out and said, all those things that I said almost 30 years ago are true. And that's why I say I should be bitter, but I'm just happy. You know, and my my old age, okay, I'm I'm vindicated. You know, I'm I was right. It's like it's like with you when your wife finally admits, yeah, you were right. Doesn't happen often. I've never no, no, I've never experienced that. Well, you I'm married 48 years, so it's it it's it it happens son uh maybe in 46th year finally.

SPEAKER_03 32:53

I'm only I'm only 20 years in, so maybe I'll get maybe I'll get there eventually.

SPEAKER_02 32:58

No, you gotta you got a ways to go before they'll admit. As I uh my youngest son, who is now a surgery resident, I told him he's just got married, and and I and I said, this this you don't ever want to win an argument. Because if if if you lose the argument, they're happy.

SPEAKER_03 33:18

And if you happen to win the argument, your wife will never forget that, and she'll remember 10 years later and say, You you said Yeah, she's one of the most competitive people I've ever met. And and she'll she'll admit this. We used to play um right when we first were dating, we were dating when when shortly before turning 18. And so we were playing games, you know, like Risk and Rummy and all that kind of stuff. Yeah, and um, and we played, we would always play a game until the first time I beat her, and then it was a new game. She just doesn't handle it well.

SPEAKER_02 33:54

Yeah, well, that's like my wife and I play Batgammon together, and and uh we both learned at the same time, but I I I was better than she was. It just it's my personality, and I was winning all the time. Then I realized I gotta let her win sometime because if I don't, she's not gonna keep playing. Yeah, we but now she's now she's very good. She's she's figured out the different ways, you know, and what you have to do and the risks. So now it's a competitive game, and I I don't let her win. She wins. But but yeah, you got to keep them in the game. You know, it's like your kids. You if you're if you're playing basketball or baseball, you gotta let them once in a while feel like they're succeeding and beating you, you know.

SPEAKER_03 34:34

Man, my son, he uh he's eight and he took up, he decided he wanted to do chess camp. He'd never played before, and he went to chess camp this past this past summer, and he comes home uh like the very first day. He's like, Dad, I want to play you in chess. I was like, okay. And so he sits down and I'm like looking at my phone, like not play paying attention, like three moves in, like takes my queen. I was like, okay, like put down the phone, like, and then he and then he proceeds to just like stomp, stomp my wife at chess, like over and over again. And we're and there was uh, and so we were we're we've been humbled, humbled by our own child. But that's if you're gonna be humbled by somebody, that's a that's a rewarding one to be humbled by.

SPEAKER_02 35:17

Yeah, my my oldest son, who's now uh in his 40s, he he is of the old era when when uh computer sports first came out, and so he was about eight-year-old, nine-year-old, something like that. And and it was Larry Bird versus versus Magic Johnson basketball. Okay, and we're playing, and he knows nothing about basketball at this age, and and every time I take the ball out, he would steal it because he was so good with the with the joysticks or computer or whatever it was at the time. And it drove me crazy. And finally I said, I can't play with you anymore because you can you won't let me get the ball down the court. But yeah, your kid, your kids are the best thing. So uh yeah, it and it and to me, and I'm sure you, the most important thing is your family. So your you know, your boys or your daughters or whoever teaches you have, you live for them after a while.

SPEAKER_03 36:20

So yeah, I've got one of each. Um, you know, obviously you were a very high-volume surgeon, had your hands and a lot of academics as that part of your career. And I'm sure you traveled a lot with that aspect of your career. How did you manage to to maintain that connection with your family and and your relationships?

SPEAKER_02 36:41

Well, I don't know if I did that great a job some with some of the the boys. Uh I had three, I have three sons. One of them, unfortunately, has passed away. My middle son passed away from a from a brain tumor at 30 at 32. Uh and he and I traveled, you know, when I was when I was home, I would be with him. He was on a traveling soccer team. So we bonded over over that. We would travel all over California and some outside California playing soccer. So I bonded with him. Uh my older son, I wasn't around that much. And my young, my youngest son, who's now finished medical school and is figuring out what he's gonna be doing, uh we we he always complains, he says, you were never home. But now that he's uh a surgery, first year surgery resident, he calls me every day and he's telling me about the patients and what would I do and so on. So we're rebonding. But I but I think it, you know, I I traveled way too much from the early 90s until uh 2020, until COVID. I mean, I was traveling all over the world. And so I was a way too much. And and the price I'm paying now is I have my wife says, well, you went so-and-so, now we have to go there together. So we so now if people are always because I'm on Facebook a lot, people see our travels. We do a lot of traveling together and as a family, uh, much more. But it's it's a difficult problem. Uh, and I uh you don't want to forget your kids because they grow up uh very fast. They're before you know it, you know, they don't want anything to do with you for a while. Right. But but they come back. But let me warn you, they come back, you know. So it's uh so so it it you know, there's that period in in high school and and even early college where they want to be independent.

SPEAKER_00 38:33

Yeah.

SPEAKER_02 38:33

But uh, but for my but my two boys, uh especially when my middle one passed away, we've become very, very, very close. Uh here's a picture of up there of my three sons. So all got mustaches now. So and and two of them are bald. Well, two of them are still with us are going bald like me.

SPEAKER_03 38:50

But yeah, me too.

SPEAKER_02 38:51

But we're we're we're yeah, we're very close. And I think if I can give you one tip, it's don't ignore the kids because as you know, before you know it, they're gone for a while. They come back, uh, especially fortunately or unfortunately, COVID was a thing where they came back to live with us for a while.

SPEAKER_03 39:12

Yeah.

SPEAKER_02 39:12

Uh so it was a good thing, good and bad.

SPEAKER_03 39:15

So yeah, it's it's a really weird time. You know, I'm in my career. My career started very uh in a like up until I came into practice, my career went almost flawlessly. It was just kind of, and then I really stumbled out the gate with my with my starting in my practice. And so whenever I kind of got things turned around and things started rolling in the right direction, especially here recently, um, you know, opportunities they come in bunches. And and and some success and opportunities breed other opportunities. And so what I'm really struggling with now is kind of determine, you know, I know that I'm a finite, a finite being here, determining when and where to say no. And that's really kind of where the where the road meets the road. In our practice, for instance, you know, we're trying to to really start to delegate uh some of the things that previously we were very heavily micromanaging. And um, you know, that's a whole other whole other side of leadership is is choosing the right people to delegate to and being okay when they do things, maybe not the same way that I would have done them. But I do think that that's kind of the that's kind of where I'm trying to find that balance because I do think that I'm working too like too many hours to really hold my uh my kids and and my wife and those relationships to the level that I really that I say I want to, but really in practicality I'm probably not living up to that.

SPEAKER_02 40:42

Yeah, it's it's it's very tough. And and you know, when I was in uh you know, for the most of my career, I've been was in private practice until I semi-retired in what was in 2013. I took a new job where I worked for a hospital to set up a bariatric unit. Uh and in private practice, you can't the the number one thing is you can't say no to someone who wants to refer you a patient. It's all about available. One of my partners used to say who he was uh uh from from Tennessee, and he he, if I can use the word redneck, he was a redneck. So it's an interesting combination of him and me, you know, little Jewish boy and a redneck from the south together as partners. So it was very interesting. But he used to say it's the three A's availability, uh affability, and the last A is ability. Yep. He said that's how you get your referrals is if you're available, they refer to you. If you're nice, they refer to you, and then they will learn whether your patients do well. Yeah, uh, and so that private practice is a little different than academics. But I've told, I don't know if you know, I have a very good friend who's at Mayo, who I've mentored through the years, who's now moved up and he's a professor at Mayo Clinic. And what I tell him is that you know because he's traveling a lot, and I said, Don't ignore your kids. You got two two young little kids, a boy and a girl. You gotta be there because uh they're they're gonna grow up.

SPEAKER_03 42:16

Yeah.

SPEAKER_02 42:17

Uh and they won't know you. And you know, my older son still to this day says I wasn't around enough, but now we're we're good buddies. He's we do things together and um enjoy each other. Uh and the same thing with my youngest. Uh but it but you can't you can't get those years back. But it is it's a it's a tough thing. And the same thing in academics. I mean, with you the traveling thing is it's hard to it's hard to say no because uh you like you enjoy what you're doing. You for me, it was teaching. I love teaching. I mean, I've been teaching uh laparoscopic technique, whether it was hernia uh or gallbladder or then bariatrics, adrenalectomy, so on and so forth. That's that's been more fun. And for my students to become really great, it's more is you know, it's like your kids. Yeah, uh, you really enjoy that more. When you see a resident or or one of your people flourish, one I won't give you a name, but there's someone who who attended both two of my things and I taught, who's now quite more famous than I am. Uh and and it's great because it that means I must have done something right uh and succeeded. So teaching's fun.

SPEAKER_03 43:29

It is. I I was not always the best teacher. Um, I think that I got better after I had kids, actually. And you're right, because there's a there's a weird, uh it's like a weird parent feel, and um much more patient than I used to be, you know, and probably even have that kind of like dad disappointment when things aren't going well, you know. It's a little bit of like like, oh, you can do better.

SPEAKER_02 43:53

But but you're in the era where you have to be nice. See, I've been I'm from the I'm from the era before. Me was even worse, but but the days of Zollinger and those guys, those guys were crazy. I mean, they they I could tell you stories of uh the what they used to do to residents, which was total insanity. You'd be arrested today if you did what they did. But when I the first half of my career, you we weren't nice to residents, you know, and you you could get away with almost anything. And now you can't discipline anybody, you can't, you have to be do it in a nice way and make them feel good and and so on. So it's it's a tough, tough transition for an old guy like me. But some people, one of my nurses, I had the same nurses for years, and and and my my nurse would say, Boy, you've mellowed over the years. And I would just say, No, I'm exhausted. I have to know. I can't, I can't too much energy to to to to slap them around anymore, you know.

SPEAKER_03 44:56

But yeah, no, I think it's uh it's it's interesting. I think we have, you know, the the pendulum's always swinging, right? So you come from the times when stuff was probably was definitely not probably not good then, uh, but you know, definitely wouldn't be good now, um, all the way. And then and there's probably some happy medium in all of this that that makes a little bit more sense. But yeah, it's definitely there's definitely an art to being um to holding people accountable and and not being malignant about it. Um, but I think that that you know it's it's one of those deals that yeah, it's it's different. I mean, I try I try very, very hard not to be the person that's like, you know, back in my day I would have because I think that they've got the truth is is our um They don't want to hear that. Yeah, well, and the the truth is our residents like right now, they're actually learning more techniques um per surgery than they even I learned, and I've not been out that long, you know, and so you know, we weren't there was you know, realistically when they're going to learn how to do a hernia repair in the groin, for instance, they're really learning at this point three different, three different uh not techniques, but three different modalities that you can fix them with. Um I think convincing them that it actually is the same technique, just with a different tool, is probably something that you would agree with. But but I think that um it's a different it's a definitely different levels of stress that they have now than we did back then. And I do see some of the residents coming through that are just incredibly skilled.

SPEAKER_02 46:26

Yeah, no, I and when you talk about that, I think one of the advantages now and and and why I've swung in robotics of my saying robotics is a good thing, is I I don't I don't think the results of robotics are any better. And no one's for anything, no one has been able to show that, even though people claim it. When you look at the numbers, the results are basically identical to whether you do it laparoscopic or robotic. I think the advantage to the robotics has been the learning curve. And and that's for multiple reasons. And one, there's simulators now, so you can do all this stuff before you ever get to the OR with a simulator, you learn the anatomy. You know, you know, it's sort of like learning to fly a plane from a simulator before you take it up and crash it. And and so that's number one. And number two, if you have dual consoles, you can the hardest thing for me, especially not so much for hernia, but when I was teaching bariatrics, I had a fellowship for five years, uh, a certified fellowship. And when I would teach them, I I would take them in a certain way. In other words, I would break a gastric bypass down into steps, just like I did with hernia. And and so they would start out, they'd have to be able to complete step one efficiently, because I never thought anybody should be on the table more than two hours for a gastric bypass. Because I can do one in an hour and a half, they should be able never more than two hours. So I would say, okay, you do step one. When you can do step one and and complete that, then you get to do step one and step two, and so on and so forth. Because for a gastric bypass, particularly, even anyone with hernia, you you go in an orderly fashion. So it it that allowed them by the time my fellows would reach six months, they could do uh pretty much a whole procedure. And then with the next six months was getting their time down to what I thought was great for the patients. And also, I had a technique, as you probably know as someone who teaches, from the other side of the table or whatever the assistant, you could actually be doing the case and they don't even know it.

SPEAKER_03 48:43

We call it ghosting.

SPEAKER_02 48:44

Yeah, yeah, yeah. You're you're exposed, you're exposing everything. Yeah. So I'll give you a tip. Do this with your residents. By the time they're they're competent, you should be assisting them as if you were an imbecile. In other words, you don't move to give them exposure unless they ask for it.

SPEAKER_03 49:08

Yeah.

SPEAKER_02 49:08

Because one of the things I found when people came to me for my fellowship in in minimum invader surgery, they'd say, Oh, I've done all these gallbladders and I've done all this. I said, Okay, go ahead. And and I and they'd start doing it, and if I wasn't giving them the proper exposure, they didn't know what the hell they were doing.

SPEAKER_00 49:26

Right.

SPEAKER_02 49:27

And they had finished a residency. And I said, Then did what did your attendings do? And they said, Well, they operated and first assisted me, and I did it. I said, Well, you're gonna go out, you're gonna go out in the real world in another year. Yeah, and there's nobody, you're gonna look over your shoulder like this, and where's that guy? Yeah to give you the exposure, whether you're doing a hernia or you're doing a bypass or whether you're doing adrenalectomy. And so that was what I did as a teacher is to take them through that and then eventually get it to the point where they had to tell me as the first assistant where to put where to hold the stomach or where to hold the peritoneum if I was doing a hernia. Because it when they leave, you're not Luke's not gonna be there.

SPEAKER_03 50:12

It's baffling. It I mean, it happened to me when I came out. You go, you get out there to do your first case, and it was I can't remember what it was. It might have, it wasn't my first case, but I think it was just like a straightforward open umbilical. And I'm like trying to do this, and I'm like sewn in this like hole, and I'm like, what is going on? Like, how is this so hard? I just did, I was knocking the and then I realized that like you know, the scrubs like holding things because it's not just it's not just them not retracting, half the time they're retracting the wrong way, or like they're running the camera and they're like staring at the wall, and you're like, no, over there. And and um, and then you get to the point where you're like, Oh, I see, or the number of times that like somebody's like here, and they just like reach over and like like holding on top of your hand, like operating for you with like like your own hand. So you're like, Oh, yeah, I didn't actually do that case, did I?

SPEAKER_02 50:59

No, I mean it I think that that's exactly right, and that's what what you have to teach them. Uh, it's funny when I would be working with somebody, uh, and they would be first assisting me, supposedly, and uh doing a laparoscopic case, and and they would try to move the camera. I said, You don't move. I'll tell you when to move and where to move. Yeah, you don't you you you do not, you know. My own partner would drive me crazy because he thought he could do the case, and I'd go, Don't, don't move. That's what that's why robotics is so nice, is you're controlling controlling the camera, not somebody who thinks, zoom in, zoom out, you know. Oh yeah. Yeah, so you're doing it, you're doing it all. You got in fact, with the new robots, you you got there's a picture that would that we that it's funny, way before robots, okay, there was a slide to describe, and I can't remember who put it up there, and I used it later, but I didn't come up with it. This is a perfect laparoscopic surgeon. And it was a picture of a guy with three or four hands. The surgeon had three or four hands, and so now you have you know, three or four hands. You can you can control everything, and that's what it really you want to do.

SPEAKER_03 52:13

Well, what I found is it exposes uh teaching on the robot exposes weaknesses that otherwise may not have been there because you are controlling your own retraction. And so when the residents set up their retraction, the thing that I find robotically that I didn't catch as much whenever I was holding, you know, two of the sticks for a lap coley, you're watching them do a robot Coley, they're when they're retracting, they don't it exposes poor left hand. Like if you're they don't, it's like the times when they're like struggling, and I'm going, that's because your left hand has been sitting completely still for the past five minutes. You know, try to tell them it's like your left hand's doing the case if you're a right-handed surgeon.

SPEAKER_02 52:53

I was very fortunate in the early days. Uh this is going back to 1989, 1990, when Lap Coli first started. If you look at the original people who did Lap Cole, nobody was using their left hand, almost nobody. Uh, one guy was, and that was the guy who I was lucky enough to hook up with at my first pig course, and that's Joe Patlin. Everybody else was teaching you hold the camera in one hand and and operate, and and the assistant is the is the left hand.

SPEAKER_00 53:29

Yeah.

SPEAKER_02 53:30

And Joe Patlin said, and this is back in 1989. He said, no, you learn to operate just like you do open, and you use your both of your damn hands. And I and I I it's funny because I don't Joe and I are very close now, and and I tell him, he's also unfortunately old like me and retired, but I tell him, all the bad things I've done in life are because of you, Joe, because you were my first mentor in 89. So you're you're and he laughs because you know he knows we're both we're both uh pretty pretty good surgeons. But but I said, yeah, you're responsible. You were you're the guy that told me to use that left hand, and that's that's what you say is exactly right. If even today, if you watch a lot of laparoscopic surgeons, they're they're not using both their hands like you would when you do it when you do an open case.

SPEAKER_00 54:23

Right.

SPEAKER_02 54:23

They're using their right hand, or if they're left-handed, left hand, and they're not doing the retraction. Whereas when when I learned to do it, and when I taught others, is you're using both hands, and all the assistants doing is they're your fixed retractor. You just you you you take their hand and put it here. Don't move, buddy. Yeah, you know, that's it.

SPEAKER_03 54:43

Yeah, we uh it it's um, and then the other thing I've been harping on a lot of our our chiefs recently, uh, you know, just trying to they can get to a case. I'm not worried about that. But by that level, they're they're proficient in that aspect, but trying to get them a little bit smoother. And so it's the not having the static retraction. So as you're releasing things, you know, that left hand, you may have a good exposure, and then you release the tension, and then the left hand never moves for the next two minutes, and then all of a sudden they're like digging in holes. I'm like, well, that's because the they're attracting, it's a it's a dynamic motion with both hands, and so it's funny because you point out those things and you see it click, and that's actually really rewarding because then the next time you watch them, you're like, now that was nice, you know, and those are those types of things. I think as I've come further in my career and gain more confidence in my own abilities, it's a lot easier to see the successes of others and and feel good about that.

SPEAKER_02 55:36

Yeah, I I think what you pointed out earlier is is you don't learn from your as much from your successes, you learn from the things you did wrong and not to do those. You know, it's so it's sort of like hopefully the Michigan quarterback next year is gonna learn from from the mistakes he made over the middle this year. We'll we'll see. Yeah. But yeah, yeah, I think you learn, you know, there's nothing like experience and and having tough, tough cases and and learning. But I think the other thing that I want to bring up is that you've got to learn to admit if you were wrong about something. And I think that I pride myself that that's one thing I've been able to do. I've been able to, if I may have said something five years ago, but if I've learned something in the interim, I'm willing to admit I was wrong and change what I do, like about robotics or or or other things. And it's that abil ability to change uh and admit you're wrong, uh, and not stick to anything, uh, that I think that I think is important uh you know to to stress because things are things are evolving, uh things are changing. I think one of the things you talked about big squirtle hernia's in the past, and and uh when some people came up with the idea when when Vaughn up at NYU was in Portland, Nicole and and Malcher came up with the idea of a ban in the sack. Everybody started going, that's crazy. And I said, No, that's probably I never thought of that, because I was one who dug out every huge scroll hernias that were down to the knees. I was wrong. There is a technique where you where you I think abandon the sack is an important variation, not for every case, correct, but for big big scrottal hernias, it makes total sense, especially when you think about when you do an open hernia, you always abandon the sack, not always, but a big scroll hernia. If you do an open technique, what you do is you cut it, tie off the proximal sac, and and and leave the this still this still one open. So why not laparoscopically? It's the same thing.

SPEAKER_03 57:51

Yeah, I will uh I will say I wasn't gonna mention that in this this episode of the podcast. I wasn't sure your opinion on that aspect, but uh but I have uh you can mention anything. But I was like, I don't want to get tarred and feathered, but no, I you know the we we I did that the first time I abandoned the sack was actually before the the one of the more recent papers came out about the two different techniques about like the keyhole or the the donut. And and um I actually was doing I had a patient that I needed to do this big Ingwen Scrodal, but he had a lot of heart issues, and he was very, very symptomatic. And so what I did is I was I talked the door with my partner beforehand, and I was just like, this guy, I gotta get this guy off the table and get him off the table quickly. And I can't remember exactly what it was. I don't remember why, but I was gonna I needed I was gonna do it robotic. And so I went in and we had considered just doing it open under local. We had gone through all the iterations of it. So I went in and I just key, I just put a went to the internal ring, made my incision, dropped it back, sewed it closed, did a repair, and put a skirtle support on him. And that guy had and started his um and started his heparin drip back like real quick after surgery, just like a few, like two or three hours after surgery. And um went to see him the next day, he had like zero pain, like had the most amazing, had the most amazing recovery. And I was I went and told the partner, I said, you know, I did this as almost like a bailout maneuver just to try to get this guy to where he wasn't having these, I think he was having like obstructive type symptoms and things. I was like, I did this as a bailout maneuver, and he looks better than the guys that I'm doing the whole thing on. And uh, and so we we did that and we actually could kept a list um for quite a while. We kept a list of all of them that we did it on. And um, you know, we're eventually we'll have the moment we're get the get that data out there. But it's it was something that I'll tell you, my my experiences has been very, very good in the right patient. Um, and the one thing that I think you'll really appreciate though is the thing that I tell people. I was talking to one of our other partners about this. I said, if you do it though, you have to pull that sack from the side and get the cord lipoma out. I said, Yeah, well, yeah. That's the I said that's you can't just do everything.

SPEAKER_02 1:00:06

You can't abandon a step here, you know. Exactly. Yeah, no matter which technique you get rule 10, you know, exactly you gotta do that. But but yeah, I I think that it it's funny that to hear people who were were jumping on against uh what those people were preaching, and I'm going, why? In fact, uh one of the one of the if we'll see what happens with my session at in August, but I've invited someone uh because my session is it is the following the steps, and I'm at having someone try to show that as part one of those is that doesn't violate the steps. Uh and we'll see it has to get approved before it go goes forward. But but yeah, I I think there are things like that. There's certain things that I'm still very much against, if you want to know those. And I I would jump on you, and that is I don't think you need to try and close a direct, there are all these guys who are trying to put stitches to close a direct floor. There is no, I mean, I've done somewhere between five and ten thousand hernia. I've never closed a direct floor. There's no reason to close a direct floor, and there's a tremendous risk of trapping nerves when you close the direct floor. So I don't see the sense of it. If you want to grab the sack and pull it out like Jorge does or a few other people, fine, that will decrease seromas. Uh but I I I I'm probably the I probably aspirated more seromas than any other human being today since I've been doing these, was doing hernias for 30 years and doing big scrotal hernias. I got my share of scrotal seromas. And so they would come back to the office every week or two weeks or every month and put a needle in and suck it under local, and no, and they all disappear. The key is uh if you don't, if you allow a seroma to exist for more than three to six months without aspirating and do something about, it will become a contained saroma or like a hydrosil. So you can't you you can't you can't you have to either you you can watch it disappear, but if it's not disappearing and you leave it, I can guarantee you it be it will become encapsulated, and then the person will have a not an extra testicle. Yes, yeah, which they don't like, they don't like, they don't, they don't think what an extra one is better.

SPEAKER_03 1:02:35

No, no. Um I will tell you though, I you know, I have some people I know that they intervene on saromas that like the post op first post operative visit. I usually don't, I wait, I give it because if you I've found that if I wait, and I'm not saying wait a year, but if you wait, like I will see those people back every few weeks until it and make sure it's getting smaller, but vast, vast majority of them. I've had to intervene on very, very few. If you give them, you know, two, three months, they'll usually go away. And if they aren't, then you gotta interview, you gotta do something. But you know, smaller.

SPEAKER_02 1:03:10

My philosophy was that if is I if they come back and they have a saroma, I tell them it's not a recurrence, it's fluid. If you want, I can show you by sticking a needle in it, but but it's probably gonna disappear. If it doesn't bother you because it's not painful, then just leave it and we'll watch it for for three to four weeks and see what happens. But I totally agree with you. But I I I think that if you leave it more than a few months, and it's not if it's disappearing, that's a whole thing. When I had my my my re uh David Chen did one of my I had Nihoo, when I was an intern, nihoose did an open repair on my hernia. That's a whole nother story. He kept dropping the the weeks before, he kept dropping his glasses into the wound. So you know those those little things that come around and hook on your glasses? Yeah, I bought him a pair of those. Please open them with the groin, yeah. But before he did my hernia, I said, here, Professor News, please put these on your glasses. He laughed. And he did, and he did he did my hernia under local as an intern. And the the I was on PEED surgery at the time, okay? And those days, but you were in the hospital for hernia repair. So I stayed overnight. But guess what? I had to do in the hospital that night. I had to make rounds on my patients. That's how bad. So I one night I'm supposed to be post-op and I'm rounding in the hospital uh uh on my patients, uh, pediatric service. So it's ridiculous. But but getting the getting back to saromas. I I don't think you can leave it for a few more than a few months if it's not disappearing. Correct. Because it will encapsulate. And and or if the patient complains, I mean, if you do if you do a big enough scrotal hernia, they're all gonna get a big fluid collection.

SPEAKER_03 1:05:03

And and you know, you know the ones that actually don't that I've found are the ones where I abandoned the sac just past the internal ring. Like they don't know, that's it. What's funny because we we put them in the scrotal support for a couple of weeks and we leave them there. And I can't remember, a couple of patients had other issues, and so we want they end up getting scanned for other things. And the fluid that I think would have probably been the seroma is like in the in the like perivasicular space, you know, in the space of Red Sias. There's fluid there, but it's actually not down. I had one that's good. I had one guy that I did a full, I sucked the whole thing out, and he had no seroma. And he shows up um he or yeah, I got it's something to do, but you know, he ended up reaccumulating fluid at a weird time. And I go back in there and I'm going, This is weird. You shouldn't be having fluid like two, three weeks after, like, I don't know what's going on if there's like a connection or something. Anyway, so I get a CT scan on him, and he had fluid all over his belly, and he didn't. Have it when I was there before, and I'm like, this is really weird. I was like, you've got like some ascites going on or something. And he wasn't, he wasn't a drinker, and so he and he had good heart. And he ended up getting diagnosed with uh uh like stage four calangiocarcinoma, and it was all because like the whole only thing they knew, only thing we ever knew is that this guy's fluid showed up in his groin, and I just couldn't figure out like what was going on, and it was I think it was actually it might have been actually that same patient that was that I'd done on the ant on the anti um platelets and on the heparin drip, but it was just it just nothing made sense, and so they came back to me and they were like, We want to thank you so much. You got him, you helped him. So I was like, Oh, well, Rob then's like, Yeah, you helped get him diagnosed with uh calangiocarcinoma. And I was like, Well, that's not really the thanks that I was wanting.

SPEAKER_02 1:06:54

You you you just you've just proven uh an old adage, better lucky than smart.

SPEAKER_03 1:07:01

Yes, yes, no, I thought that's been that's been my life, like better lucky than smart.

SPEAKER_02 1:07:06

Yeah, I I remember uh I had a case where well it was like the my first week or second week in in private practice in Fresno, and I was covering for my partners, and this patient comes in uh at nighttime with a with an acute abdomen and and uh uh looked like a perforation of a colon of some kind. And so I went in there, and the patient was scheduled for my partner to do a coley, open coley, and and the gynecologist to do some ovarian thing the next week. But this patient presents to me the new Nubian town, sicker than than heck, in the middle of the night with a perforation of some kind, and I went in there and and looked at it, and there was this mass around around the appendix, and I said, This this is not appendicitis, this is this looks like cancer, because I had been a surgeon, I was a cancer surgeon. I said, This is cancer, this is something wrong. And and I'll never forget the I called the uh pathology to come in and do it frozen in the middle of the night, and the guy looks at me and he goes, uh guy named really super Carl Chen. And I Carl looked at me and said, What are you crazy? What is it? There's nothing, you know. I said, just take it and do it. And he he said, I'm not doing a frozen. He said, So I did a did a right colon and and got it, and it turns out that the guy had a carcinoma of the gallbladder, metastatic to the cecum, which is then perforated on my watch.

SPEAKER_03 1:08:54

Lucky you.

SPEAKER_02 1:08:56

Yeah, that's just so it's lucky. It's just like this is crazy, you know. This is so your case reminds me of that. You know, it's sometimes better lucky than than than smart, but yeah.

SPEAKER_03 1:09:06

My uh my case that I was in that I was like, well, this is really interesting, and I'm really sad that it's mine. I um was it had a guy come in with a mid-bowel obstruction, and couldn't, we couldn't, it wasn't even mid, it was actually like just not far past the ligament or trice, but was obstructed, looked like there was this mass or something, couldn't figure out what was going on, and uh ended up in the operating room with him, and he turned out he was a patient that was on full everything for Crohn's and was still completely uncontrolled. And he had a gallstone Ilias between Crohn's strictures just past his ligament of trites. And I'm like going, oh no. And so I'm like, you know, you try to like milk it back, it like won't move. It's like perfectly in between these two strictures. So I'm just like cut it open, pulled the stone out, sewed it closed, you know, said a few, you know, prayers and sent it on. He did fine, and he came back to my office a few months later and he's like, You gonna take my gallbladder out? I was like, How's your crumbs? How's your crumbs? He's like, still really, it's like we can't control it. I was like, You need to see a petal biliary, you know, send him down there, and that battle biliary surgeon was like, Nope, not touching that. So hopefully he's doing okay. But that was what that was a case where in the middle of it's one of those in the middle of the day, or you're just going, I don't know how I drew this straw, but they did not have this in the textbook whenever I was going through residency.

SPEAKER_02 1:10:26

No, that that's what experience is. But uh how how do you think it is now? I mean, one of the things that we that everybody is doing a fellowship almost. Very few people are going out from a general surgery residency and going out in practice.

SPEAKER_00 1:10:43

Yeah.

SPEAKER_02 1:10:44

Do you think it's do you think it has to do with the time limits on their uh education? In other words, these shifts. I don't know. I know I know my son now has to do like 12-hour shifts at night. Totally different than we did. I tell my wife, we never did that. We just we we we did every every second or every third day, we just stayed. We never left. But now they do they, you know, with the 80-hour work week, supposedly. Yeah, is it they're not getting enough experience or what what's what's the problem there? Because I think education is is really important.

SPEAKER_03 1:11:17

Yeah, so I didn't I didn't do a fellowship. Um, I went straight into practice, and really my first few years in practice were probably more of my like on-the-job fellowship. Um, but I think that I think it's multifactorial from what I've seen. And I can only speak to to our program. I think more and more people are going into fellowship from our program, and I don't necessarily think that it's because they can't operate. I think that there are places out there that that's probably the case just because whenever I was, even when I was interviewing for residency back in, well shoot, that would have been 2009, um, 10. That's um, that was whenever I was interviewing for residency. There were places that the residents were very honest, and they just said, like, listen, our case numbers were barely, we're getting, you know, 800 major cases and but getting a lot of other experience, uh, you know, research and this and that, but really need that last year or two to really solidify our surgical skills. And they were very honest at a few places I interviewed. Um, I think there's marketability in a lot of ways. Um, a lot of the people that go into it are wanting to do things very specific that realistically, I don't think the pathway, at least what I'm seeing, the pathway to be um a specialist by being a general surgeon that just does a large volume of it and then eventually becomes that. That doesn't seem like that's gonna be that possible. And I think that I'm probably lucky that I've been able to get into um, you know, I'm not a full-time hernia surgeon, but I definitely do a heavy hernia volume. And I think in the root in the future, probably that's probably gonna not be as much the case. I think mentally invasive fellowship trained surgeons are probably gonna be more uh more in line for those types of jobs. And so I think there's that. I also think that there's a little bit of the fact that even through the period of my training, and definitely before me, and through my training and even now, I think there's a lot of pressure on um like medical legal pressure on the autonomy that we give residents. And so, you know, always being there in the room for me um was a huge difference. Like I've said it before on the podcast, but you know, the first time I was doing a lap coli and it came time to cut the cystic duct, and I looked around, and there's like nobody else in the room that's gonna tell me if it's the common, you know, you're sitting there going like this is a big deal. And so, but I know that a lot of places, you know, at least whenever I was in medical school and stuff, there's a lot of times that residents were operating with the attending nearby, but not in the room. And so I think that that kind of experience was very valuable, but it's not really realistic with some of the pressures that are put on even the teaching faculty, even if you're doing a case and they're getting those numbers. But and then and then also I just think everything's getting so specialized.

SPEAKER_02 1:13:58

Um things have changed dramatically from from I'm an old an old fart, as we say, uh, from when I train, because uh it was actually the second year is that when I was in a second year of my being an attending at the University of Illinois, that the rules changed. Uh and then I then I left at the third year, fortunately, because I the rules would have hurt me. But when I was in training, uh we except for certain cases to learn from, the attendees would were during, were not even there. Uh they would show you how to do a gastrectomy and do some with you, but but you basically, you and the chief resident were doing the cases. And so we had tremendous amount of experience. I think the biggest thing for me was and my my boss, Dr. Daskupta, when I as a surgical oncologist, said that that first year for me being an attending, in other words, I went from resident, chief resident at the University of Illinois, to the attending running basically the county oncology service, doing commandos, head neck stuff, whipples, uh, four-quarter resections, hemipilfact, all kinds of major stuff, uh, is exactly what you said, is I no longer had someone to look back at. I was it.

SPEAKER_00 1:15:17

Yeah.

SPEAKER_02 1:15:17

You know, I had to make the decision. So that is the toughest transition. And I think it's it even for someone who has a fellowship, it's that first year afterwards that is the scariest year because uh unless they're like you are at a university and there's a bunch of guys, you know, you can call someone more senior. And I see that happening uh at at universities. That it's funny. I do I used to do a lot of medical legal stuff uh and stuff that I would do the whole case. I mean, I had a case where, okay, the guy at UCSF sees, well, there's something goofy with the colon, so they call a colorectal surgeon in. We never, we never did that, we just did it all.

SPEAKER_00 1:16:00

Sure.

SPEAKER_02 1:16:00

Uh and and I and I think that it's that first year or second year, but hopefully only the first year, where you don't have someone, don't have Luke behind you or next to you, or Luke on the phone uh to say, what do I do now? And that's the advantage, I think, of being uh not out in the real world, but at a university. You can always, you know, uh call a partner or call someone else to come to the room and give you another opinion. But when you fin when you have your residence finished and they go back to Oklahoma and they're in a small town uh and they're doing the surgery, there ain't nobody else.

SPEAKER_03 1:16:39

No. It's uh the the importance of partners when you come out, you no matter what your training is that first year, the importance of the group you join and the partners you have, I think really sets you up for success or or struggle in early in your career. Um I you know that transition, that transition from residency into being an attending was so difficult for me that that's actually something that I've I'm really passionate about. Um and I think one of the main and realistically, um this podcast is a spin-off of that passion in the fact that one of the things that I experienced very strongly is whenever I got out and I had those moments of doubt, and I was in a situation in my first year or two, or for me it was longer than that. Um, my learning curve on things, my perception of my learning curve has always been longer than normal. I think the reality is probably that I just am so much of a perfectionist that, you know, it I it it extends in my mind. But whenever I came out, there was a there was a level of feeling lack of confidence that I never saw any of my other attendings express. And so whenever I was experiencing that and I realized it, for me, it made me question my confidence. Whereas it was more probably a natural transition, that that fear, that looking over your shoulder and going, like, nobody's here, am I doing the right thing? Man, this is a lot of pressure. Or heaven forbid you have your first complication, and then that really shakes you for a minute, you know. And those are those are the situations that that I think are normal and part of the growth process, at least in my opinion. But I don't think people were talking about it openly and talking about how difficult it was. And it it one of the reasons that I say that is because I can remember very vividly when the people that never expressed it did express something about like losing sleep over a complication or this or that. It was so rare that it like it jarred me, and I remember those vividly. But I very I've been very, very open with my residents and my trainees about my own struggles. You know, about the, you know, for instance, like this month. This month it's been, you know, I told them all, I was like, listen, I've been a little bit short. We've been waiting on a on a biopsy result off of a tumor off my wife's knee for the past eight days. And so, you know, luckily it came back this morning benign. But, you know, to say that to say that life doesn't affect you in your career and that we're some sort of like able to completely compartmentalize and able to come out of training, even if you do a fellowship completely confident, and it put that and and not express that that's not a lot of people's experience. There are some people that I'm sure have feel that way, but that definitely wasn't mine. I think it underestimates how hard it is in that transition. And I think that's one of the reasons why people maybe go to fellowship more frequently is because they don't understand that some of this stuff is actually normal. You're not like failing or abnormal, it's just nobody was talking about it.

SPEAKER_02 1:19:45

No, I I I I get what you're saying entirely, and I I worry about the the surgeon who doesn't take to heart and doesn't worry that if if someone asks me, now that I'm retired and I wish I wasn't, but that I'm because operating is like is but to me, I liken it to a football player when it's over, you don't know what to do unless you become a broadcaster. And so maybe I should become a bro a surgical broadcaster.

SPEAKER_03 1:20:14

It's your first gig right here.

SPEAKER_02 1:20:16

Yeah, but but I I can remember every case that didn't do well and learn from everyone. I worry about the surgeon. I I had a I've seen surgeons that they're very cavalier. You know, there there's a thing people will do something crazy and they say, Well, I got away with it, you know. And I and I went, No, you didn't get away with it. The patient did. You're you I I can now sleep better at night. That's the only thing that's about retirement that's been good. I mean, I did some pretty hairy, complicated cases, especially in the uh in my previous life, and then in when I was semi-retired, in quotes, working three or four days a week, uh doing complicated bariatric stuff. I would worry every night when I would do some ridiculous case and not sleep. Now I don't I still dream about them, unfortunately, but I but I but I don't you know wake up and all very often thinking about what's this patient doing. I mean, and so I worry about the surgeon that doesn't take that to heart. You that is important to feel uh inside you. You that those people are family when you operate, and they're trusting you. You should be able you should be objective, but you have to be to feel about it. I mean, uh so I'm totally with you, and I worry about those surgeons, and there are plenty of them out there that that don't have that sense. They are just I don't know what even the word would be, but they're just operating. And if something goes wrong, oh well, that's just the way things. No, that's not the way things are. And so yeah, I I think what you say is very true. I don't know if I'm babbling at this point, no, but it it me but it means a lot to me that that I that as the person cares about their patients uh and cares about if there's something goes wrong because yeah, you're responsible.

SPEAKER_03 1:22:23

Yeah, it's you know, it's I've had I've had really some conversations with people who I would have categorized exactly what you're talking about that don't care. And then I've had some conversations with them that you know I've put I really truly a few couple of them. I went out on a limb and kind of expressed to them that I was struggling with some with some ruminating about some complications. And then they open up about the fact that you know they were losing sleep or that this was like just destroying their well-being. And I'm going, you know, it was it was shocking to me because I never pegged them for that kind of deal. And I and I almost wanted to say, like, you should probably express that sometimes because the puppy the opinion of like your bystanders is that you don't give a crap at all. You know, so I don't, it's kind of one of those deals where I I don't know if it's because they don't care or maybe they just don't express it the same way that I do. There's possibly, I'm not definitely not saying there aren't people out there that are that are probably on the more on the spectrum. I see a lot of people blame patients for the complications where I'm just like, yeah, you know, ultimately that was it was you. But then the but my biggest pet peeve, and I am always harping on this with the residents, is you hear people say, well, it's not malpractice. The the the gap between good quality work and malpractice is so enormous that if you're basing your quality on not getting sued, there's a whole lot of of help and benefits that you could give to people that you're really leaving on the table. And so I I I always tell them, like, you should be practicing not just to not get sued. Like that's that's I mean, if you're doing the right thing, you you know, stuff happens and stuff happens outside of our control. And listen, it's bound to happen, but if your bare minimum is just not getting into a a lawsuit, then I think that you've got a real, you've got a real, you're maybe leaving a lot of quality on the table.

SPEAKER_02 1:24:18

Yeah, but there's even a bigger, there's a another problem with that is when you're when you're doing things just to not get sued, you're you're you're not there are certain times when it pays to take risk. Yes. Okay, and then you weigh you weigh the risk versus the benefit. And I talk about that a lot. And so if you're if you never are willing to take certain risks, because then you're not you're gonna leave a lot of benefit on the table. Yeah, and you're gonna leave a lot of people, and that was very true for me, not so much in what I with hernia or or bariatrics uh uh well, except the complicated bariatrics revision stuff, as it was with cancer surgery. I mean, you you sometimes have to take calculated risk, but it's a risk versus the benefit. You don't want to take a risk if there's if the benefit far if the benefit doesn't outweigh that that risk. So I think yeah, you can't you can't just be a defensive, I mean, I hear that as you say it, but well, I I'm not gonna do that because that could be mal, you know, someone if you have good reasoning to do something and it's a proper thing, then sometimes you have to do it even though it's not uh but that doesn't mean doing crazy things, you know, and and and and going back to hernia, for example, uh just because you can do it doesn't mean it it's the right thing to do.

SPEAKER_00 1:25:48

Correct.

SPEAKER_02 1:25:49

Uh and what uh uh for example, and I I don't know how you put this, but uh patients post-radiation for prostate CA. You're probably much say I I have been roped into too many times going back laparoscopically and doing their hernia when they've had radiation. And every time it happened, and the last one I still remember because it was my anesthesiologist's father. And and I I almost wanted to kill my anesthesiologist head to says, Why did you why did you make me do this? It would have been better off with an open under local hernia repair, even though I don't think that's a better case, better operation. You take the risk. Yeah, uh eight out of ten times I can get away with doing doing it laparoscopically. But why should I take the risk of injuring two people? Now, I think the opposite is true for someone who's had a previous laparoscopic repair. I think personally, every one of those patients should be at least re-laparoscoped tap-wise and look to see why it recurred. Especially if it's your case. Especially if it's your case. And then my feeling is if you're good enough, like I'm not saying I'm the greatest surgeon in the world, but I mean, I I can do almost any recurrent or could not anymore, but could do recurrent laparoscopic hernias, refix them laparoscopically.

SPEAKER_00 1:27:21

Yeah.

SPEAKER_02 1:27:21

But I would say to the person who doesn't have that skill level, they should at least put a five troll car in and look and see, because there's you're gonna see why it recurred. Yeah. You're gonna whereas if you go open, you're never gonna know.

SPEAKER_03 1:27:39

That's I mean, yeah, no, I agree.

SPEAKER_02 1:27:42

And and and you know, if it's your own if it's your own case, you're not gonna learn from it.

SPEAKER_03 1:27:47

Yeah, so if you put a bothers me, yeah.

SPEAKER_02 1:27:49

If you put a five scope in and you say, Oh, the mesh the mesh rolled up, you know, there as I put it, it could be lateral roll up, medial roll up, total roll up, roll up, you know. Whatever I forgot the light poem. At least you'll know. But if you go anteriorly right away, you first of all, I don't think the repair is going to be as good. It could be. People are maybe David Chen will argue with me, but but but but I you know I I think you won't know why it recurred. So I think it's you know, you should take a peek and at least look. And if you're good enough, go for it. Go for it. But if you're not good enough, then don't. But I would say the opposite of true, and I've done enough with radiation or previous radical prostates. It's not you can do it. And there are people publishing huge series about doing it, but for the average surgeon, should they be doing it? No. Yeah, the answer is no.

SPEAKER_03 1:28:46

Yeah. Yeah, that's yeah, that's uh that is one that we my partners and I discuss not infrequently. I still fall on the um if you've had a prostatectomy, I still do them open. Um localized radiation, I do, I'll still give it a shot robotic. But I've also I got I had a patient with total prostate, like total pelvic radiation, and even tried to do that open, and even that was hard. Um that was that was a very that was a big mess. But yeah, no, those are those cases are those cases be tough, and I I completely understand what you're saying. There's been a couple of of recurrences that I've had that I've taken back and done an open repair after having previously done a a robotic um or a laparoscopic repair, and it it eats at me not knowing exactly I have a good suspicion. I have a very, very strong suspicion, and I did modify one of my one of the things I was doing to make sure that that that didn't happen, and luckily it hasn't happened again, knock on wood. But but yeah, I think um I think that that's that's uh that's a really good tidbit.

SPEAKER_02 1:29:49

As we get to the end of uh yeah, let me tell you one more personal story about hernia in a way in a way. Okay, I unfortunately at the beginning of COVID, I got my own prostate cancer. Okay. So I I went up to I I shopped around, I called all the the intuitive people and see who they thought the best robotic prostate surgeon was. And they gave me a list of uh of four or five. One of them was actually down where you are, but the other one was the UCSF. So I went up there and I and I said to the guy, I said, uh, I've had bilateral posterior recurrent hernia fixed laparoscopically, and I have mesh on both sides. I said, I don't think you're gonna be able to do the obturator or DPL, you know, notes because my mesh is there. And the guy who, very good surgeon, but world-famous surgeon, he goes, Oh, I've done many of these at UCLCF. That mesh is never a never a problem. I said, Okay. So I went ahead and had my radical my radical prostate done. And and uh after he says, you know, I couldn't do the the the nodes, your mesh was all the way down covering the the operator fossa. I said, Yeah, that's where it's supposed to be. And so we we were we'd never done it. This is now six years ago. We were gonna collaborate because what he was saying is most of the people he sees at a prestigious university, I don't know whether they're coming from outside or where, but their mesh is nowhere near where it's supposed to be. Sure. And he and he, as a urologist, had no idea where it was supposed to be. He just knew that that when he's these people come with inguinal hernia repairs posteriorly with meshin, they're not a problem.

SPEAKER_03 1:31:40

Yeah.

SPEAKER_02 1:31:41

And so there a lot of people out there not doing it right.

SPEAKER_03 1:31:44

I had I had this exact conversation with our urologist who's very, very skilled and very uh he has a lot of experience. Literally a month ago, he came to me and he go, he sent me a patient. He goes, uh he goes, This patient has bilateral recurrent like directing vino hernias after I took his prostate out. And I go, okay, that's fine, send him over, I'll take care of it. And he goes, he goes, Man, I don't know what the hell that surgeon was doing. He goes, there was mesh all the way to like the pubic symphysis. Oh, the pubic to the pubic symphysis. And I go, I go, right. He goes, uh, he goes, I don't know. He goes, it was mesh. He goes like the whole he's like the whole pelvic floor was like covered in mesh. He goes, I go, yeah. And he goes, Well, I mean, what was he doing? I go, he was doing a an actual repair of an inquilar hernia. And it was funny because he was just like, no, no, no, it's usually all just like a little tiny piece over there by the cord. And I'm like, well, yeah, you know, it's that's a lot of them.

SPEAKER_02 1:32:46

So here's a study for you, okay? I didn't do it. You should do it. It's combine with with your urologist who does the robotics and have them have him do a series of taking pictures of the hernias and whether the how many, what percent of the ones he sees that he won't know if it's supposed to be in the right place, but you will be if he takes the picture. And and I think that that's worth publishing because someone needs to get out there that there's a whole group of people doing hernias that aren't even coming close to the first nine commandments, let alone the tenth.

SPEAKER_00 1:33:27

Yeah.

SPEAKER_02 1:33:29

They're not putting a 10 by 15 mesh in there. They're they're and they're not going three centimeters below the pubis, and they're not covering the space of rest. They're not they're not doing it right. And it's and then that number is much more than you or I think. Oh, yeah.

SPEAKER_03 1:33:45

In other words, the number the number of incorrect hernias. Well, it's the it's the uh it's the did a 15-minute bilateral immunal hernia. White. But did you do it well? That's the question, right? I can do a lot of things really quickly. It may not be very good.

SPEAKER_02 1:34:04

Seven minutes aside, that's I I can't do that.

SPEAKER_03 1:34:06

That's yeah, I mean that's uh that's some of the stuff.

SPEAKER_02 1:34:11

That's like running 100 yards uh in less than 10. I can't do that either.

SPEAKER_03 1:34:17

Well, I uh at the end of every episode, we offer people their opportunity to give their their hernia hot take. I know you've had a lot of a lot of takes throughout the episode already, but if you have any one, if you have one stored up for us, we'd love to hear it.

SPEAKER_02 1:34:30

Yeah, I the only hot take I would take is that hernia repair, whether it's inguinal or ventral, is totally, totally unappreciated by our insurance colleagues. I mean, it's an interesting, I don't know if you know the fact that when they came out with a code for laparoscopic inguinal hernia repair, because the patients did so much better could get back to work two days later or ride my patients who are bicycle enthusiasts and racers could go back to riding the bike the next few days, that we shouldn't charge as much. And therefore, the code for laparoscopic inguinal hernia repair pays less than open. Yes. And the same, I bet you is true for ventral hernia repairs. So that's my complaint, is that somebody needs to get to the insurance people and say, how about you? Would you rather be on the table and get this or that?

SPEAKER_03 1:35:37

So yeah. Well, I think that that's uh that is a hernia hot take that's going to be uh appreciated and felt by by the majority of us out there doing this. It's it is uh in unfortunately at the moment, it doesn't feel like it's getting better or easier. It feels like it's getting a little bit worse here recently. So hopefully we can kind of make some progress. But again, sir, we really, really, really appreciate you coming on. It's been a fantastic conversation. I've been looking forward to it for a while. So I'm just so glad you took the time to talk with us.

SPEAKER_02 1:36:08

Yeah, hope to see you at uh American Herne Society in in in Denver. I'm only gonna be there one day because I have to leave for Japan the next day. But uh we'll be there and I think look for me, look for me there.

SPEAKER_03 1:36:22

I think we may even have a hernia uh uh hernia gods podcast uh presence there. Maybe have a booth to get some get some on the on the spot hot takes.

SPEAKER_02 1:36:34

So you you should you if I could add one other thing if you want is you should you should hook this up, your podcast, somehow hook it up with General Surgery News. Yeah, uh they would love that. I I will talk to them and see if I can hook because I'm as one of the editors there. I think what you're doing is really nice, and and maybe you could somehow combine it with them in some way.

SPEAKER_03 1:36:57

Yeah, I'm all about trying to to get the word out there because I think that we have a as surgeons, we have a lot more shared experience than I think we realize. And um, a lot of the things that make this job uh rewarding can also be very challenging, and uh the it's a lot easier to to handle it if you know that you're not alone.

SPEAKER_02 1:37:17

Yeah. Well, thank you for having me. It's been it's been a fun, fun pleasure.

SPEAKER_03 1:37:21

Absolutely. Well, we appreciate it. This will be the wrapping up this episode of the Hernia Gods Podcast. This is your mere mortal host, Luke, signing off. Thank you all so much.