The Hernia Gods Podcast E20 - Gregory Dumanian, MD

Episode 20 of The Hernia Gods Podcast features a great conversation with Greg Dumanian, MD about his early work in plastic surgery, the role of aesthetics in hernia surgery, and mesh suture!

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 Elms. 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. Hello, and welcome to another episode of the Hernia Gods Podcast. This is your Mirmortal host, Luke Elms. Today I'm joined by Dr. Greg Dumanian, and we sure appreciate you coming on and joining us today.

SPEAKER_02 0:37

Oh, thanks for letting me uh participate. This is great.

SPEAKER_03 0:41

Absolutely. Well, you know, we start um yeah, before we get started, you know, the I was saying before we came on, uh back at American Hernan Society this year, I had the opportunity to meet you, and um, and we had talked at that point just a little bit about uh the whole the whole um uh idea, and I was super uh um interested in kind of the way that you got where you are in your career and what you're doing now. And so it had you were one of the uh baseline inspirations to have these types of discussions. So it really is a full circle moment for me for me for you to come on and have a have a talk with us.

SPEAKER_02 1:15

Sounds great. Again, uh my pleasure.

SPEAKER_03 1:18

So why don't you start by telling us a little bit about who you are, where you come from, and how you got where you are.

SPEAKER_02 1:24

Well, uh, I'm the son of a very uh well-known uh cardiac surgeon. He came from uh uh originally Aleppo, Syria, and then Beirut, and then the United States. He came in the late 50s and had an extremely successful cardiovascular surgery practice in northwest Indiana at that point. Northwest Indiana was the richest county in the entire country because of all the steel mills and factories and refineries. And uh I looked at a lot of different things of what I wanted to do, but uh you know, I kept coming back to maybe I should just be a doctor. And then those days of doing surgery as a medical student, it's like I really need to be a surgeon, just like my father and my great uncle and his father before then. So we come from a long line of surgeons. Um, I went to uh the University of Chicago where um I was interviewing at a whole bunch of residencies, and uh I ended up at the Mass General Hospital. So hardcore general surgery, 120 to 140 hours a week. Uh, I was telling one of my residents this morning, and I got married, and then I was in-house every other the next 10 months. So super, super demanding. And uh while I was there, I uh decided that I really wanted to be a plastic surgeon. Um, to do a lot of hand surgery, not general surgery. And I thought, oh gosh, I shouldn't, I don't want to be a cardiac surgeon like my dad, but hand surgery really is what I want to be, what I want to do. So I went to the University of Pittsburgh for uh plastic surgery. That was uh a year of research and two years of uh two years of uh plastic surgery training, and and then I did a hand fellowship after that. But while I was at Pitt, um, you know, the story of why Pittsburgh was associated with the components release is a really funny story, um, which you may not know. The anterior component release was uh done by Ramirez, but Ramirez was a general surgery, a nice guy, Oscar Ramirez, and he did it at the Union Memorial Hospital when he was in Baltimore. He did the dissections at Union Memorial, which is where I did my hand fellowship, by the way. That's where I learned this whole story. And then Oscar finished general surgery at Union Memorial, came to Pitt. He was there about 1989, where he started to do his component releases at the University of Pittsburgh. Okay, so or maybe it was 92 that he he wrote it up. So then I was there 92 to 95. So the first big cases I was doing were anterior component releases, and that was just a throwaway, you know, these uh uh what I mean a throwaway, you'd be doing real plastic surgery things, and then they're like, hey, close that abdomen for the transplant surgeons. Okay, so we would go down and we would just do it. And um, this very vivid patient, I walked into this room, and uh 350-pound guy, and the plastic surgeon had lifted up all the skin flaps, and I said, Hey, can I help? He goes, Yeah, Tabani, close this guy. So I just walked in and just started closing his back shut. And again, I had done general surgery, so you know, I'm fine. And then that guy had the most horrific wound complications, being 350 pounds and having these undermined skin flaps. So I took care of that guy for months. So that always stuck in my head. And then uh I'm getting to how I'm a herniar surgeon, and then uh one day I was in conference at the University of Pittsburgh talking about this guy who had had an aortic tube graft and then had an anterior component release. We called it the separation of parts then. So that was the name, the separation of parts. And we he had had his tube graft and had a hernia, and the resident lifted up the skin to release the external oblique muscle and fascia to get his abdominal wall together. And you can imagine if you lose your peri-ambilical perforators and then you lose your intercostal blood supply from the tube graft, this guy lost all the skin of his abdominal wall. And uh I was in MM, and the guy next to me, Ken Chesteck, said, you know, why couldn't we just go around those perforators and do the same thing? So I was on one side of Ken Chesteck, and the plastic surgeon on the other side, the resident, went to the University of Texas, I think at Austin, and he was the one to do the first uh component release with perforator preservation. That was the first description. Okay. Anyway, so that little segue from that. Um I went and did my hand fellowship, came to the university, I came to Northwestern as my first job to be the local hand surgeon, full-time faculty. But at that point, Northwestern had a very bad town gown problem. Half of the surgeons were private, half were full-time academic. And the orthopedic surgeons shunned me from being a plastic surgeon. Sorry, being a hand surgeon, excuse me. And I needed something to do. And my first big case was a fascial dehiscence with an open abdomen and entercutaneous fistula. And uh no one knew what to do with them. I said, I used to do these all the time at Pittsburgh. I would just skin graft the act, open wound, uh, we convert the wound into a fistula, put an ostomy bag, let the patient get better, and then we would do a component release. And the general surgeon was like, Well, if you know how to do that, you take care of this patient. So my first big case in Northwestern was a hernia abdominal wall reconstruction, which I had written up at Pitt. And then I got a couple infected meshes, midline meshes. And so then I just excised the mesh, plastic surgery principles, did an anti-component release, and they all did fine. And so this idea that I'm a hand surgeon, but not really having much hand to do. And then the real need at Northwestern was for a hernia surgeon, abdominal wall surgery. I'm like, well, I can do that. I'm a general surgeon and general surgery trained, and I know how to do this anterior component release. And then remembering Ken Chesteck and that MM at Pit, I started going around the periodical perforators to do these releases. And I was having, you know, it was like the complication rate above just the laparotomy. So I had a gimmick that worked that made these cases to be done in two, two and a half hours with low complication rates. And there was no one else in Chicagoland doing it. This is 2002 that I wrote up the anterior component, the perforator preserving component release or separation of parts, which is why people, when they look it up, don't find that article.

SPEAKER_03 8:44

I see.

SPEAKER_02 8:45

It wasn't called an anterior component release. We called it the perforator preserving separation of parts.

SPEAKER_03 8:51

Oh, okay.

SPEAKER_02 8:52

Based on the old name. And by 2009, I had done hundreds of these anti-air components, and we wrote that up, and it was we had an article in Annals of Surgery on perfor on component release, archives of surgery. And for a long time in Chicagoland, um, you know, I was one of the dominant hernia surgeons only by accident. So that is the story. How did a plastic surgeon who's really wanting to do hand surgery become a hernia surgeon? But then when I think about it, an abdominal wall surgery is just putting two tendons together, which is the whole thing of hand surgery. In hand surgery, when you when you cut your flexor tendons, the collagen is very lined up very linearly. And so plastic surgeons, hand surgeons have all this intricate stitching of flexor tendons so that you don't get suture pull-through. Suture pull-through is that concept when a tendon repair falls apart, it's not because the suture breaks, it's because the tendon has cut through the tissue. So to a hand surgeon, suture pull-through is one of the biggest obstacles of doing successful surgery. And as I'm doing hernia surgery, I'm recognizing it's the same problem.

SPEAKER_01 10:18

Yeah.

SPEAKER_02 10:19

The stitches which you put in the fascia cut through the tissues and you get failure. And that's my that's my story or entry into the hernia world.

SPEAKER_03 10:31

Yeah, that's that is uh that's fascinating. So yeah, so it's kind of interesting. You know, a lot of people that come on on the podcast um are about the posterior separation. And obviously, it's it's funny because a lot of the um from you know, from the things that I was taught coming through, a lot of it was a concern about flap preservation in the anterior component separation. And obviously, that's one of the things that you identified as a problem very early and then and then solved it. It sounds like just the the way that um you have thought about the procedure and the limitations of the procedure, and then subsequently the failures of the procedure have come from a very uh different thought process than majority of hernia surgeons, and a lot of that comes from your experience as a plastic surgeon. I think that that's that's pretty fascinating considering that you know we we come from things at different angles, and it really, when you get those ideas that merge, it can be a brand new way of thinking of something that that other people may not have thought of just because of experience.

SPEAKER_02 11:33

Well, um, the to me is a plastic surgeon. Um the real the world of general surgery has moved away from anything that has anything to do with skin. You don't, um not not that you can't cut skin, but you uh you're just not familiar or trained to deal with the complications of skin elevation, which is aromas and abscesses, and um and so from the plastics world, uh it frees you to do lots of different things if you can see the abdominal wall, work on the abdominal wall, and not worry about what's going to happen to the skin for the post-op healing. So it's just part of our specialty, and so um we gravitate to skin, you know, we think of or plastic surgeons or myself think of hernia world as two different surgeries. It's the abdominal wall surgery, and then there's the skin tailoring on top. Yes, and they're related, but they're independent questions, yes, and so then the most versatile surgeon for the hernias should be able to manipulate both independently. Now, the classics world doesn't do MIS surgery, and that is one of the limitations of our training paradigm that I don't do collapse at Mass General, I did the first non cholosystectomy laparoscopic procedure, which was I mobilized the left colon and brought it up as a uh diverting uh loop, a diverting end colostomy. That was the first non-Coli procedure done at Mass General. But after like 10 laparoscopic procedures, I left the general and uh haven't done one since. So uh so I I uh I think that um bringing the two worlds together, the skin players and the non-skin players, or the MIS people and the skin uh um uh experts, that is what's going to provide the best overall hernia care. And um Mike Rosen, who's now at Northwestern and I, have had a really fun uh year since he's arrived at Northwestern because it's just two different thought processes coming together.

SPEAKER_03 13:53

Absolutely. Yeah. Well, it's it's you know interesting because I we take care of these large hernias that uh the redundancy of the soft tissue over the top of the fascia and the you know the the distortion of the soft tissue due to the hernia sac is always something that I you know it's not ideal, right? And so many times those end up being staged procedures where we take care of the take care of the hernia itself and then they come back for you know an abdominal plasty uh later with our plastics team or something like that. But really the limitation of that um is the fact that you know the abdominal plasty many times can't get the coverage. And so the limitation of finances really contributes to getting the hernia repaired, but maybe the aesthetics aren't what they really wanted. And that is where I think that we have a lot of room to grow as far as being able to take care of the whole patient. Some of that's you know, surgeon limitations from experiences, some of that's just systematic limitations from the finances of it all. Uh, because ultimately I would love to do combined cases with my plastics colleagues all the time because I think that you know the cases I've done together are um they've cut turned out just beautifully. But um, but yeah, it's it's a really interesting thing.

SPEAKER_02 15:10

You were talking about the tendons being I was gonna I was gonna go back one thing. The York Journey Center at UK, they're friends of mine, um their patient um outcomes, the highest um patient-reported outcome improvement after hernia repair is the aesthetics.

SPEAKER_03 15:29

Yes.

SPEAKER_02 15:30

The patients care more about the aesthetics than they care about hernia recurrence or immediate post-op wounds. So if you're really going to provide the ultimate uh procedure that has to or should be part of the equation.

SPEAKER_03 15:45

Yes. Yeah, I I agree. It's uh and and the you know, the the performance of that aspect of the procedure has you know tips and tricks and techniques that are not obvious. And they may seem uh obvious, or yeah, you just kind of do this and this and take a little extra tissue, but the the um the outcome very much depends on uh depends on a lot of factors that that plastic surgeons obviously take into account on a on a daily basis. And uh and general surgeons are looking more at the the you know structure and function of the deeper layers.

SPEAKER_02 16:20

I agree. Um because your toolbox is let's go deep and leave the skin alone. And until the general surgery world can play with wound complications, saromas, necrotic skin, um, managing those as an outpatient in a very expeditious manner. Well, then the the worlds will stay apart. And uh and that's that's not the best thing. But then again, two individuals coming together with different skill sets, that works too. So um totally reasonable.

SPEAKER_03 16:52

Yeah, it's a it's uh, you know, it is definitely part of when we've kind of moved into more uh the larger hernias. Again, uh, I've said it before on the podcast, really like the point that you just made, when people come in to talk to you, uh I have found that you can go and do a really good hernia surgery on somebody and not accomplish the goal that they came to you for because their goal wasn't even necessarily the hernia. And that um, and whenever that finally kind of clicked with me, um, then I got very specific about asking for their for their goals. And it is always a tough situation to be in, and a lot of extra counseling that I go through whenever I do find a patient that their goals are yes, hernia repair, but a lot of it is aesthetics. And so you I get those over to our plastics folks. They come back and they're like, listen, I, you know, I need the hernia fixed, no doubt. We all agree on that. Um, but uh, really can't afford to move forward with the other aspect. They don't have, you know, the paniculitis that can be documented as uh to justify that aspect. And I don't know if there's room for um improvement of our documentation or the way that we can get these these things approved to get them some help, or or maybe we just need to explore more of a systematic patch package-based approach for the way that these can be they think outside the box, so to speak. But but it definitely does require more when we realize that it's not just the hernia that they're looking for.

SPEAKER_02 18:20

Um what I do in my office is I'd say a third of the patients will pay extra money to do what we call skin tailoring. We're not really full, we're not calling it an abdominal plasty, but um that's what it is. And there, but uh I want to free your brain to it's not all it's a low transverse incision. So a lot of I do vertical abdominal plasties, I've read I've written on it, where I will do a you know, the way I put in a retrorectus mesh. Um, I will, you know, go into the abdomen, uh close posterior sheath, put in what I call a seven and a half centimeter wide and narrow, well-fixed mesh. Very different than the way um uh general surgery tends to let them in. I'll use a mesh suture on top, and then at the beginning of the case, I'll do transverse lines equally spaced with staples so that I can help to line up the skin at the end of the case. And then I will do most of my excision in a vertical plane, and then I will uh sit the patient up about 30 degrees and in the suprapubic area or the underwear line for a guy, and then we'll do essentially a dog ear transversely, and I can do a narrow, well-fixed mesh with a full essentially abdominal plastic in about three hours. And then the hospitalization, at least the post-operative care, is covered by the um uh by the hernier care. So they just have the one hour of OR time and the surgeon's feed to do the extra skin. Otherwise, um oh, and and to make an umbilical. So at the same time that you excise the skin, you leave little two by two centimeter what I call pumpkin teeth flaps, and you take those skin flaps and tack them down to the abdominal wall, and you recreate an umbilicus. So then the scar is broken up by the indentation of the umbilical area. And uh for plastic surgery, the it's called the aesthetic subunit. For the nose, there are particular types of places you're supposed to put an incision. Well, for the abdomen, it's the vertical, you already have that indented line. And so then if you have a vertical line with an umbilicus, it becomes very acceptable. And so, in the worst cases of rectus diastasis, I will convince the patient to have better balance between the upper and lower abdomens to actually do a vertical abdominal plasty.

SPEAKER_01 20:52

Yes.

SPEAKER_02 20:52

And overall, the uh acceptance rate is very high.

SPEAKER_03 20:58

That's interesting. Yeah, so you just for this is I've I have I have increasingly increasing numbers of these types of patients, exactly what you're talking about. Um, you know, my my wife's an OBGYN, and so um I get and then um here in Orlando, uh, we have one of the largest um in our system, we have one of the largest OB hospitals in the country. Uh I think it's like 14,000 deliveries a year. And um, and so whenever we see an increasing number of women that come in for just massive core weakness with the associated constipation, uh, the back issues that are associated with that, and and the pelvic floor dysfunction that all kind of interplays. Um, and they come in for these massive diastases. I have a couple in my practice right now, they're between 12 and 15 centimeters. And so these are you know, obviously big, uh big things to deal with. You when you are talking about tailoring them with a vertical abdominal plasty, you are removing the umbilicus and creating a new. Umbilicus, is that correct?

SPEAKER_02 22:01

Every time.

SPEAKER_03 22:02

Okay. Yeah, because that's been, I will say, that that has been my biggest struggle because again, whenever you do, if I do it open for a size that big and you pull it together, it's hard to get things to line up because they're because if you're trying to maintain the umbilicus, it's there's like this this pull of the anterior way.

SPEAKER_02 22:21

So I do transverse lines at the beginning, I do a vertical line between the zypoid and the symphysis, and then I do transverse lines. And you know, it doesn't matter where you put your staple 10-12 centimeters wide on the skin. Then I will go in for the worst cases, I'll do what I call a mesh abdominoplasty, and I'm doing transfascial sutures to I usually use an 11-centimeter wide mesh for that because a normal female rectus muscle should be pre-partum, pre-you know, uh someone who hasn't had children is six centimeters wide. Yes. So if you do an 11-centimeter wide mesh, you take bites, usually like 10-11 centimeters from the medium borders of the rectus, you're pulling the semilunar lines together, and actually it bunches up the rectus muscle, which has been all stretched out. And so then again, the marks of female beauty, we did an internet-based study, is a vertical linea alba and the semilunar lines. That's the first three things that um men and women look at for female beauty. And so one of the problems I have with tar releases is that it destroys the semilunar lines, right? I mean, you go you have the posterior components. So you destroy the semilunar lines, the abdomen looks kind of round, and you're moving against female aesthetics. It was a female study, not men, but having that semilunar, that lateral border that you can see through the skin actually is kind of important. So when I'm doing abdominal plastics, when I'm doing vertical abdominal plastides, I try and save that attachment of the skin to the lateral border of the semilunar line to help recreate that. And I just want all my fixation right in the midline as opposed to posterior component release, which just by friction is using a huge mesh. So to me, posterior release is working against the things that I want to achieve in an abdomen.

unknown 24:30

Yeah.

SPEAKER_02 24:30

So that's why I only do posterior releases on rare occasions for deep flat bulges or um breath, you know, breast reconstruction-related harvest site bulges where you have a low transverse incision, you don't have good rectus muscles, the semular line connections have already been elevated. So I do a tar release on them again because they um that lateral aspect, you don't have the rectus muscles to pull together in the midline in those cases.

SPEAKER_03 25:00

Yeah, one of these days you're gonna be in the operating room and look over your shoulder, and I'm just gonna be like peeking over to see what you're doing because that I need to know. I have a have quite a few patients I think would very much benefit from that knowledge. So yeah, no, I think um that no one has ever no one has ever watched me do surgery other than my residence.

SPEAKER_02 25:19

I have never had a visitor ever. 30 years. Well, come on now.

SPEAKER_03 25:24

I'm there. I love Chicago. I just got done watching the Bears, so I'm all about going up there and eating some fine dining.

SPEAKER_02 25:32

It was just the best game ever in my life. Unfortunately, unfortunately, I've not seen the best football game I could ever see, which was that onside kick during regular season. I mean, you can't you can't get any better than that.

SPEAKER_03 25:46

Yeah, my brother, my brother is a Hemonk doc up in um up in Chicago. And so he lives he lives in one of the uh uh condo condos there overlooking Navy Pier. And so he was, but um, you'd be sad to find out that he's actually a Packers fan. And so he uh was listening to the celebration and it was a bittersweet moment for him. His team lost, but he also is he my brothers wanted to live in Chicago. He but we grew up in the Oklahoma Panhandle and we had like zero connections to Chicago whatsoever. Um nobody lived there, nobody had ever been there. Like we're just farm boys in Oklahoma, and he for some reason, from like the age of five, he was just obsessed with Chicago and um decided he wanted to be there and and ended up going to uh up there to uh uh to Loyola and then and then went through his fellowship and now he works up there. And so I I love Chicago. So like I said, I'm I'm down. You just let me let me know. I'll come observe. Well, you know, one of the things you were talking about was the mesh pull through and the fact that the Linea Alba uh is a tendon. I don't think, I mean, yes, I I it obviously is a tendon. I don't think I ever really thought of it that way. Um, just from a just from a logic standpoint. Um, is that so then the mesh the suture pull through, was that really one of the first things that made you start thinking about mesh as an alternative to standard suture?

SPEAKER_02 27:10

So um, yes, I I had seen so when I wrote uh 200 anti-component releases lessons learned, I had a 23% recurrence rate at almost two years. And if you look up the if you do a standard laparotomy, close with sutures, the hernia rate at three years is about 23%. So there's some factor of you know, in a certain number of people, the scar that's created from a suture is not strong enough. Not a kid, yeah, it is gonna be strong enough, but you know, you uh a scar is only 70% as strong as the tissue is replacing. So, in a certain number of people, if you're just using a suture, it is not enough. Even small bites, the famous small bites, the uh it's so it trial at five years, as a you could see the recurrence rate every year just getting higher because an absorbable suture, when it goes away, leaves scar. Scar in certain people is not strong enough long term. The scar remodels and fails over time from the pressures applied. The bigger you are, the more the pressure. And early on, right after you place that suture, you have suture pull-through. And so then the uh the scar, the the linea alba is stretching and poly back in 1987 with metal clips showed that if at one month, if you put right after when you do a laparata, I mean you put clips on either side of the abdominal wall, if you take a plain film at one month, if they're nine, if there's 15 millimeters between those clips, there's a 90% chance you're gonna develop an incisional hernia. So suture pull-through happens immediately, and then over time that scar where the pull through happened fails 23% of the time. Even when you do component releases to reduce the tension. So reducing the tension is important, but it doesn't solve the problem. And then what about a permanent suture? Well, we all know that when you see a permanent suture, you can just strip it out. So a permanent suture has no permanent hold. Okay, so absorbable sutures and permanent sutures have the same laparotomy failure rate, but for different reasons.

unknown 29:33

Okay.

SPEAKER_02 29:34

Okay, so then um I I've been thinking, then you know you have those cuts on your fingers from your posting hand, right? You got those when I was a mass general resident, Ron Malt was the uh senior one of the senior surgeons, and we used to do he used to do something called the Superman closure. At that point, there was something called the number five at nylon, a number five nylon. And we would triple glove our hands to tie these knots, and we would get cuts on our posting finger. And at the evening meal at nine o'clock, we would compare the cuts on our fingers. Oh, that's a good one. Oh, did you triple glove? Yeah, triple gloved. So I knew that a suture could cut intact tissues even through an intact glove.

SPEAKER_03 30:23

Yes.

SPEAKER_02 30:24

So I'm seeing my failures, I'm thinking of this of the meals when we would compare the cuts on our fingers. And then one day it was 2011, I was driving my daughter to horseback riding, and I had a flash. How about a suture that had mesh-like characteristics to distribute the forces so you wouldn't cut your finger? I mean, I'm playing with meshes all day, right? I'm a hernia surgeon, but I'm a hand surgeon and thinking about the cuts on my finger. And literally that's how it happened. I was, and I could tell you where what block I was at when I got the idea. And that's that was the genesis of the mesh suture.

SPEAKER_03 31:07

And you started by cutting strips and kind of cutting back and forth. And is that how is that how it started taking flat mesh and cutting cutting it?

SPEAKER_02 31:15

Well, what I what I did was so we had the idea. Okay. And then we uh, you know, it's the whole university owns the idea because I'm an academic. So then we filed our provisional patent, and then um we went to the lab. And in the lab, from the excess mash that I wasn't using in humans, we would cut little strips and we started doing hernia repairs in rats. Okay, so what we did was we created a rat incisional hernia by doing a laparotomy and then closing it with some uh uh plain caca. A month later, you would open it up, it would be an established hernia, and then we were closing these little rat hernias either with a fiboproline or a tiny little mesh strip. Okay, simulating what a mesh suture would be like. And wouldn't you know it? 100% of the mesh strip stayed intact, did not pull through, but 65% of the prolines pulled through. So that's pretty good, right? So um so we knew we had something in that direction, and then back in the clinical world, you know, when I would have extra mesh after a retorectus, I started taking little strips of mesh and I'd put a snap right through the abdominal wall, and I grabbed the strip of mesh and I'd pull it through. So that was how we did it. And then we would tie a couple knots, and then I went to the lab and figured out that a 20 millimeter wide piece of uh soft polypropylene mesh had the strength of a number one proline.

SPEAKER_01 33:01

Okay.

SPEAKER_02 33:02

So I tested, I tested a centimeter, 12 millimeters, 15 millimeters, 18 millimeters. At two centimeters, it was stronger than a number one proline. And I also tested I only needed three throws. So I started using um that on the top of a retrorectus. And then um around 2015, a lady came in with her left rectus muscle completely in two pieces in an open abdomen. And I'm like, gosh, I've never seen a divided rectus muscle from trauma acutely. And I'm like, why don't you give me the mesh? And then I cut the strips of mesh and I closed her left rectus muscle, and that helped. Then I closed her midline with just mesh strips, and you know, because it was a dire situation, and that worked. And then there was this one lady very important in my career. She had a 14 centimeter wide contaminated hernia, uh, she was getting a heartman takedown. She had a skin grafted abdomen. I'm gonna do a component release, and I'm still a little bit embarrassed about using these mesh strips. So I did mesh strip and then two prolings, mesh strip and then two prolines, all the way down. At nine months, she got a hernia, but it was really an unbelievable hernia where she was intact and then she had a little hernia, and she was intact and she had a little hernia, and she was intact and she had a little hernia, and everywhere she was intact, she had a mesh strip. And at that point, I said, These mesh strips really work. And so I've probably done a thousand mesh strip cases, and it's being done, it was really being done around the world. I mean, I met I was in India at the big hernia meeting there, and uh Jorge Deas, who I didn't know, was sitting next to me, and he goes, You're the mesh strip guy. I mean, you know, and that really made me think, gosh, I'm in India, and some guy from Colombia recognizes who I am. That's really pretty cool.

SPEAKER_03 35:04

Yeah.

SPEAKER_02 35:05

Um, and so then I recognized that the idea was reverberating within the hernia community, something bigger than a standard suture to resist acute suture pull-through, and with a porosity for tissue incorporation to become stronger over time. And that multiple, and I was getting away even with dirty wounds at Northwestern with a very low SSI rate. And so I've come up with this really strong idea that multiple filaments, even though it has a higher amount of surface area, gets infected less than a big, large suture which has a big diameter filament, but even though the total amount of surface area for material is less. So the body can tolerate small filaments better than big filaments. And there is a little bit of rat data from Germany that the tissue response to a small filament is somehow more histologically normal than the tissue response to a big filament. And that also goes along with my clinical experience for chronic draining sinuses from sutures, that I have never seen a chronic draining sinus from a polypropylene suture, which is 3-0 or smaller. I've only seen I've seen one 2-0 uh 2-0 uh proline cause a chronic draining sinus. Most of them are O or one. And again, it has to do with, I think it has to do with filament size. So even though my strips a lot of filament, it's on the order of 100 microns or 120 microns, where a polypropylene suture is 400 microns, and that's the sweet spot, getting it to be a hundred two hundred or less as opposed to four hundred or more.

SPEAKER_03 37:01

So is there a case you won't use it in?

unknown 37:05

So you know.

SPEAKER_02 37:08

If we're segueing to mesh suture, you know, mesh suture has a contraindication for CDC four wounds. Okay, so if you really have a dirty wound, yes, it's surge up to the surgeon, risk benefit. And there are a few people where if you can convert the CDC4 to a CDC3 contaminated wound because of bile burden reduction and debrisment, well, then you can use an estiture. But if it's truly dirty, surgical principles, you should leave it open for colony counts to fall.

SPEAKER_03 37:44

Okay. Now, you know, you obviously the the tensile strength, I've used it uh multiple times um and use it more frequently now than I did before. So the um the tensile strength when you're pulling it through obviously is much stronger, whenever, you know, in my experience. The um is there a tension on the wound that you are more tolerant of using utilizing mesh strips or mesh suture now, um, that you're more tolerant of than you would have been in the past while doing more of a tension release, you know, expanding the procedure to release relieve more tension on the midline closure, or do you still adhere to the exact same tension release principles for the tension-free closure if possible?

SPEAKER_02 38:28

Um, that's a great question. I mean, so my I am in my hernia practice, I always just think about suture pull-through. That is the main thing I'm talking, thinking about. And so when I see someone in the pre-op state, um, I'm not even talking about prehabilitation for their what they eat. I'm only talking about pre-habilitation for their abdominal wall compliance. So lose weight, and then I have patients for big hernias, I have them lie on their bed and have their loved one push on the hernia to physically stretch out their abdominal wall.

SPEAKER_03 39:02

Oh, I see.

SPEAKER_02 39:03

That's my prehabilitation, and they can breathe against it, so their lungs get ready for that.

SPEAKER_01 39:08

Uh okay.

SPEAKER_02 39:10

So five minutes, put on a head timer, have fun, take open your hands, and I make to take a video, so I do it when they're in the office. Take a video, and then I will do the exercise. I'm pushing down on the hernia. Now breathe for five minutes. Okay, that's my prehabilitation.

SPEAKER_01 39:31

That's interesting.

SPEAKER_02 39:32

Um, and then um, and if I think they're going to need it, I'll use some pre-opotox, 150 units on each side, three weeks before. And then in the operating room, I do something called the two-finger test. And if I can take my thing, if I can take the rectus muscle, which has been dissected, and I can bring it together with my two fingers on each side, they don't need a component release.

SPEAKER_03 39:56

Okay, so one on each side and pushing, pushing together in the midline, just the two finger touching.

SPEAKER_02 40:02

This doesn't need a component. I'd say about a quarter of my patients get an anterior component release with perforator preservation to decrease the tension on the suture for uh closure. Okay.

SPEAKER_01 40:17

Yeah.

SPEAKER_02 40:18

And so then, and then um, and then there's certain situations. Let's say it's a burst of open abdomen and I'm closing it, and there's some benefits of just closing the thing. You know that there's a higher chance of getting a hernia, but you have such a benefit from closing that you're going to tolerate a little more tension, then I will do that without the anterior component release, saving that for another day when they're optimized.

SPEAKER_03 40:40

Right.

SPEAKER_02 40:41

And then a really nice trick is to put the mesh that you're in like a shoestring, and then just slowly just tighten it with your finger, and then you can close basically almost anything. Okay. So, yes, if I don't see it tear, and I with just good surgical technique and not really yanking up at once, causing tearing, then um, yes, I can close things under more that were off, but previously with a standard suture would have torn, but I can get it closed with the mesh suture successfully. So I'm doing less anterior component releases. Um, Botox is just for an elective case, but there have been patients with burst or open abdomens where I see them in the on day zero, like general surgery will call me and I'll just get the Botox and under direct vision on day zero I'll eject them.

SPEAKER_03 41:35

Oh, I see.

SPEAKER_02 41:36

With the plan of closing them at day six or seven. And that's in my hands has worked really pretty well.

SPEAKER_03 41:43

Interesting. Uh okay. And do you ever use Botox? Not only in times when you think there's going to be um uh the need that that the component separation is probably gonna be necessary. Do you use Botox to avoid component separations?

SPEAKER_02 42:00

Yeah, and like some firefighters or people like that, I really don't want to uh do an anterior component release, you know. So for but I've done a thousand anterior component releases, no one really has a problem from it because you're not removing the muscle, you're just changing its insertion. So you're weakening it a little, but it's still there, you can twist, it's still got all of its innovation. So it is not a big deal to do an anterior component. But there's some people where philosophically I really shouldn't do it. So um there was a 10-year-old who had a skin grafted abdomen, it's in the literature, um about 10 centimeters wide, she was 10 years old, and she was going to need a kidney transplant at some point. And I didn't want to release her external oblique fascia in case in her fossa that she needed something later on.

SPEAKER_03 42:50

Sure.

SPEAKER_02 42:51

So even though she was 10, she got Botox, and then I could just close her in the midline. So there are a few isolated situations. And unfortunately, again, it's not covered. But what I do in my practice, I uh sell them the Botox at cost. Okay. So they come in, they buy the Botox, but interventional radiology will put it in. There is a CPT code for that. And when I tell people they'll have less post-operative pain and it'll be easier on them and easier on me, I'd say 90% of people can come up with the funds. And for that 10%, I'll hit the rep up to say, hey, can you get some Botox? And typically they'll Yeah.

SPEAKER_03 43:31

Our experience is that uh the post-operative pain improvement is significant. And then, you know, you see them back at the two and maybe the four, the six week mark, and they're still a little floppy. We are doing mostly posterior releases, right? So it's gonna be a little different, right? Um, but over time that starts to you can see the Botox effect wear off and they do they do kind of tighten up. And that's uh it it's it's nice. Yeah, I think um it it is uh it's interesting. So you because you're From a plastics background, your hesitation about a posterior release is mostly related to kind of the concept that the transversalis muscle is like your internal girdle and that maintains the contour of the abdomen. Is that mostly your your concern with the posterior release?

SPEAKER_02 44:15

That's okay. I can go on and on on why the anterior release is better than the posterior release. Do you want to last? Do you want the the talk? Are you ready for it?

SPEAKER_03 44:27

Yeah, sure. The brief version, hold on.

SPEAKER_02 44:30

The brief version. I can do an anterior release in 10 minutes. You find me a push-air release, you can do in 10 minutes. It's not going to be done. Second, um uh my release pairs beautifully with mesh suture. The whole idea of improving the lateral abdominal wall compliance and then just closing in the midline. But a push-year release requires a huge mesh. So, from the plastics point of view, who's putting in the least amount of foreign material? Um, you know, you can still do a retrore rectus with an anterior release, but I do a narrow well fix mesh, so seven and a half centimeters wide. But a push-door release, you know, you're putting 20, 24 centimeter wide meshes. I have never in my life put in wider than a 12. Well, for the deep lap, I do some a few tars, but literally once a year I put in a 20 centimeter wide mesh, and that's about it. So conceptually, I'm gonna have better tissue vascularity, few uh less surface area that I'm opening up. So less complications. And the complications, when they happen, are more manageable. So anti-release, I think, looks better. Anti-release is faster. Um to release, you can potentially use just a suture for closure. None of those things apply for the posterior release, but the posterior release you can do as a robot. Yeah, and a posterior release, you can go home in a day, and my patients are in pain for four or five days.

SPEAKER_03 46:09

Yeah, we're probably yeah, we're probably for our for our posterior releases, majority of ours now are outpatient. And so we those folks are going home from packing. Yeah, yeah, yeah. Yeah. I've never seen Yeah, we do it, we do it at a pretty high rate now. And I think that, you know, it's uh we're we're we've been successful at it, and um, you know, you gotta choose your patients, right? You know what I mean? Like it's not a this is not a one size fits all thing. You gotta everybody's a little bit different. You just gotta pluck you know actually practice clinical medicine, not just by uh, you know, by a um an algorithm that you yeah, you gotta you gotta actually apply the right algorithm to the right patient.

SPEAKER_02 46:51

But I do think never when I say never, I'm saying my patients would never go home.

SPEAKER_03 46:56

Yeah.

SPEAKER_02 46:58

That's what I'm saying. Yeah.

SPEAKER_03 46:59

Oh, for sure. Yeah. No, I think, you know, obviously there, I think that there's definitely it's nice to have, it's it's very, very nice when you're doing hernias surgery because every patient is different and every patient has benefits from different types of repairs. And so having multiple options in your tool belt, I think has a lot of benefit for the patient. Um, you know, there's no, I I tell patients all the time, there's no perfect hernier repair. You know, and uh, and when we find it, it's gonna be somebody's gonna win a Nobel Prize. But it uh but yeah, everything has its up its benefits and risks. But if you're you know able to apply the right risk to the right patient and the right benefit to the right patient, you get really good outcomes. I think it's just really it's really neat what you do because it's not necessarily um the most common thing that we we talk about on this on this podcast or anything like that. So that's just kind of a it's an interesting perspective. But we when you do you still do some just straightforward abdominal plastics without hernias? Do you still do some of that as far as part of your practice?

SPEAKER_02 47:54

Oh, times. I did one yesterday.

SPEAKER_03 47:56

Do you still mesh suture those? Is that do you mesh suture your application?

SPEAKER_02 48:00

Every single one.

SPEAKER_03 48:02

Yeah.

SPEAKER_02 48:02

So uh low transverse incision, lifting up the abdominal skin, disinserting the umbilical stock, and then I'll run a mesh suture, usually the number one from the xiphoid to the umbo, and then another suture, umbo down to synthesis. So usually three knots. I'll start at top, do a knot, bury it, run halfway down, start a knot at the umbo, run up to it, one knot in between, and the same same thing below.

SPEAKER_03 48:27

Yeah, we've been doing some, we've done some scolas, uh, you know, with those robotic scolas. And um, and so far? Yes.

SPEAKER_02 48:36

Yeah, Flavio has done it. But again, it's the issue is uh the worst erectostyostasis, then the worst the skin.

SPEAKER_03 48:43

Sure. And if it's too big, we don't. You know, it's it's again, it's all about patient selection. And it's it's it's one of those now, you know, we're in a situation where you it, you know, you have those patients that come in and they may be a very fit female that has a very nice uh abdominal wall, but they're after their their postpartum, they've just got just enough of a diastasis that it shows. You know, like they go to do a sit-up and they're like they've got a six-pack and then the ridge, and you're going, well, you're not going to lose any more weight. And your core is obviously you've done a great job with your core rehabilitation. It's not like you've, you know, it's the right time. And and and some of those folks, you know, we worry about even in the the suturing techniques to try to make sure that you don't get the the the vertical ridge and the midline from a posterior approach and and things like that. So we've those are again, everything just goes back to patient selection and having a lot of different tools in your tool belt. In my case, it goes back. One of the things I'm a big believer in is it goes back to the surgeon themselves, knowing their limitations. And and I think that and not being scared to be like, hey, I can theoretically do this, but I don't do very many of them. And my partner does these all the time. So you should see him. That's who I would want to see. And and so those are.

SPEAKER_02 49:56

I don't do I'm a hernia surgeon that doesn't do any inquiry hernias.

SPEAKER_03 50:00

Right.

SPEAKER_02 50:00

I mean, think about it. I don't do MIS. I can't offer something that is really kind of the standard, either macroscopic or robotic. You know, yeah, I can do a shoal dice or a shoal dice-like procedure with mesh suture. I'll do it in a woman if I'm doing it on the plastic, there's an umbilical hernia, and that's a chip shot with mesh suture. But talking about um small hernias, I do lots of umbilical hernias where you know the mesh suture has in RF hand so far, no recurrences at 592 days of follow-up. So, you know, a local repair with the simplicity of a suture, but with the tissue integration and a decreasing of suture pull-through of a mesh. So that's actually pretty exciting. That um, and the Danes are just literally starting now a mesh suture trial of European hernia guidelines, a pre-parental mesh versus mesh suture. And so let's let's bring it on. There are three different RCTs in Europe that are that have basically accrued almost all their patients and now are just waiting for the data.

SPEAKER_03 51:09

Yeah, we've been wanting in our um in our practice, we've had numerous discussions about uh looking at these larger umbilical hernias uh that you know and just doing an open mesh suture repair. And I've and I've used mesh suture for um some umbilical hernias with the right counseling of the patient, you know, um, for some folks that are probably gonna need like future surgeries for other reasons. And so, you know, I talk to them, I say, listen, you know, it could could we do this and deal with the mesh and things like that, but you this is the risk benefit of everything else. And I've had a couple people that, you know, were about it, we did it, and everything seems to be going fine. You just got to make sure you you bury the knot. Or they come back and they're like, what is this? But but um, that's no different than if you, you know, don't bury the knot with a with a standard repair, too, and it's just the more permanent and more pronounced. But yeah, no, whenever it's funny because kind of shifting gears a little bit out of the technical aspect of hernias surgery and more to to a discussion about you. You were talking about you're in India and you've been at home hammering this out, and you've been doing it really, it sounds like you were doing it mostly because of the benefit you're you saw in your patients. And you started to spread the gospel with the scientific evidence and everything like that. And that's that's good. But on a on a very personal level, and you know, it's really a two-part question. One, you set out to be a hand surgeon. And did you have a situation where early in your career, when you were kind of going, hand surgery is not really happening? Was that something that was difficult for you personally and professionally? Whenever you were kind of going, actually, it looks like I'm gonna be this over here. I wasn't expecting it early in that phase. And then how does it hit you now that through all of the transitions of your career, some of which sound like they weren't planned, but just were a nice natural progression? How does it feel when you become known as like the mesh suture guy?

SPEAKER_02 53:10

Well, um, I'm gonna remind you know, what I'm known for in the plastic tutor community is actually my amputee work. So I wasn't doing that much hardcore hand, but I did a lot of cripple nerve. My teacher in my hand fellowship was really good in nerve. And so then we started doing these nerve procedures for amputees so they could move their biotic arms. That was pretty cool. That was also 2002. 2002 was a good year, and then did that for about 10 years, then we recognized that people's pain was getting better, and that was from kind of an accidental finding. So I invented this procedure called targeted muscle reintegration. I do it for chronic pain in the groins and the abdomen. Um, so for 10, 15 years, I'm really just lecturing this TMR. So I am known as a peripheral nerve surgeon.

SPEAKER_03 54:10

Interesting.

SPEAKER_02 54:11

And then the hernia thing was also just kind of happening simultaneously because chronic pain can wear you down in terms of you know how many patients you can see.

SPEAKER_01 54:20

Sure.

SPEAKER_02 54:21

So the the hernia was kind of my dependable part of my practice. And the pain patients um you know really love doing the work, but just the the surgeries are just not as predictable. Yes. So when I look back, I um I kind of people have said, what's your favorite surgery? Is it breast reconstruction? Is it hernias? Is it free flaps? And to me, I know it's weird, but surgery is surgery. If it's good surgery, it's well done. So um it has not, I do not focus on what type of procedure I'm doing, but it's doing surgery, helping patients, teaching the residents about operating. Um, that's the way I viewed it. So I even though I've done really different things in my surgical career, none of them have really taken prominence over the other.

SPEAKER_03 55:10

Interesting. Yeah.

SPEAKER_02 55:12

It's it's a different uh and I know people are like, don't you want to be a specialist? I am kind of a specialist, but I'm a specialist in surgery.

SPEAKER_03 55:20

Yeah.

SPEAKER_02 55:21

And I'm applying it to different things that I'm doing. And so the idea of mesh suture being so ubiquitous to help surgeons. Um, it's the gynecologists, the urologists, and the orthopedic surgeons, and the spine doctors, we use tons of mesh suture for spine closures.

SPEAKER_01 55:42

Right?

SPEAKER_02 55:43

Yeah, it's just putting tissue together. Um, and then it goes it goes back to suture pull through is ubiquitous to a suture. Doesn't matter how you're applying it. If I I quiz the residents, what is the biggest problem in surgery? And then they'll say something like, uh, yesterday I heard um patient access. Well, you know, that's a big problem. Or then they'll say infection, and then they'll say, and it's like, no, suture pull-through. Because if you never had suture pull-through, you'd get some vasculathromboses, okay, and you'd get some cancer occurrences, okay. But basically, all gut failures in the end are the things that the surgeons put together falls apart. Right? And so that if you had a better suture that never let tissue fall apart, all surgical complications would come down. And I have been mostly applying this concept to hernias in the hernia world, but it's really ubiquitous.

SPEAKER_03 56:43

Yeah. You know, in a very you know, so you have been successful in multiple phases of your career. And I want to get to the mentality or just kind of your thought process, because I think that there are many people out there that maybe early in their career or mid-career, even like me, that that are looking at what you've done and said, you know, if I could accomplish just one of the things that you've accomplished, that would be personally, I would consider that a pretty big success. What is your definition of success? What's your it is there a is there like an innate drive within you that makes you keep pursuing these things? Or do you feel like it's more just a curiosity or uh or is it focused on the patient more? I just want to get to kind of the mentality that it is that drives you to get to those levels.

SPEAKER_02 57:32

I'm I'm not sure I'm not sure I can answer that. That's let me just think about it a second. I mean, I drive for excellence, right? And I'm innately super curious. But um I would say, and I'm and I'm pretty thoughtful, you know, I things happen and I think about it like, why did that happen? Like the all the skin dying after the component release. Um but I would say the um the unifying factor is that I never do the same thing twice. I I can't first can't remember what I how I did it last time, so then I try something new. And I'm I'm I'm really a tinkerer, and a tinker refers to the the guys who work with tin and they're and they're just I'm always kind of just fussing with things. And um like when I walk to work, I always walk in a different direction or a different industry. I always I I don't have a one way of doing things, and I think that the openness to doing things in different ways and then seeing the outcomes and moving it a little, and uh I think is um the reason that I've been able to create targeted muscle renovation, right? Um or you know, like I saw that the way that we were handling nerves wasn't working. Um you know, it it's it's weird that you know mesh suture is the first new suture in 40 years. All these surgeons in the world and all these big companies. It's weird that I was able to come up with the first new thing. I mean, it's only the third suture design ever. But I relate it to my being a tinkerer and um and having an intuition of what's gonna work and what's not at a very simplistic level. I mean, I'm looking at the cut on my finger, and I'm like, that is not right.

SPEAKER_03 59:36

Right. Yeah. So whenever you being a tinkerer, always moving, always like progressing forward, identifying issues, having the curiosity to explore. During that process, there's obviously going to be times that you try things that don't work, that don't work inherently, that you have a failure, maybe you have a complication.

SPEAKER_02 59:57

And there's some ideas. Right.

SPEAKER_03 1:00:01

Yeah. So I'm still working on that. Yeah. So whenever you have that, I think that there's a like, for instance, me, if I'm in the if I'm moving forward with something new in my practice, I am my partner and I were very different personalities and we complement each other very well. You know, he always is, he's on the forefront. He's doing things that are, you know, hey, I, you know, if the study shows this, it's backed up by this. This study corroborated. I think we should try this. And I'm like, yeah, you should try this. And whenever you do a few, if the if the world doesn't fall apart, maybe I'll try it. And I think it goes back to the way that I think about complications. And it and realistically, I think it's more this goes back to the psychology of a surgeon and how despite us being in the same field, many people approach their life, their definition of success, and especially their definition of failure very differently. And I think that allows for people to do things. I would not be a very good inventor because I take my failures so personally. I don't take them as an opportunity to examine and improve. I do that. That's not, I'm not saying I don't like learn from my failures. But to me, it hits me in a way that it is uh very core to my being. And whenever you have a, whenever you're pursuing something and you try something that maybe doesn't work, how does that affect you personally? What's the mental what's the mental thought process that you go through when you may see a failure of a new technique and you and you realize that maybe the technique failed and and now you're kind of in this mode of fix it, or or how does that affect you, I guess?

SPEAKER_02 1:01:37

Um I'm not I'm really not trying to talk big, but um I've applied surgery principles in every case.

SPEAKER_01 1:01:46

Right.

SPEAKER_02 1:01:47

And I I actually haven't had a lot of side directions that I've gone that ended up not working. I can think of one thing. I was using nerve allographs for chronic local pain and trying to reconstruct nerves. And I put in, I treated at least 20, 30 patients like that, and then three, four years later I noticed they were still have they were their pain had come back, and I abandoned that. But in my entire hernia world, um I'm doing things really similar to how I did 20 years ago. So I I've been fortunate to have good surgical intuition and reliance on principles. And this is all based on you know being in the hospital 120 to 140 hours a week as a resident. Um I'm not saying I haven't had failures, but I I have not had some big movement in my practice that um that I wish I hadn't done. So I started doing anti-component releases with uh with just suture at a 23% recurrence rate. And then I started doing um alloderm uh or biologic mesh reinforcement. I did literally only like 16, 18 cases, and soon after I realized that it was failing, and I had a 60% failure rate on those cases, but I only did 16 of them. Okay. Then I went to intra-abdominal mesh, but a well-fixed narrow mesh trying to reduce the amount of um failures, sorry to reduce the amount of uh adhesion, adhesions and bowel problems, and I had a 5% recurrence rate. I did maybe 100, 150 of those, but I actually did pretty well, and then I started doing retorectus, and the way I do a retorectus, I've had one recurrence and four infections in my entire life. So I I mean, my I've been moving pretty much in the right direction. Um now, there's some people where I wish I hadn't done a retorectus because it physically hurts. So now I'm in the message world. And so, but I'm still doing retrovectuses. But what I'm trying to say is I haven't, other than that nerve allograph thing, it's everything I've done is is pretty. I'm not trying to talk big, but it's been working. So I haven't had those big surgical failures where I have to look back and say, oh, why did I do that? On a global level. Sure, a certain patient might you know gotten a DBT or PE, or you know, there are always those types of complications or an SSI. But patients overall, I don't have any big regrets of some direction I've made in my practice that then I had to retreat from.

SPEAKER_03 1:04:39

So you'd say that really your your success, the the so in that regard, you've been able to push the boundaries, but even in pushing the boundaries, you've been successfully doing so and been able to build off of that success. And you're what you're saying, if I'm understanding correctly, is more it's built off of the fact that despite pushing boundaries, you're basing it on stable principles so that even when you're pushing the boundary, you feel confident and you feel comfortable understanding that the basis of the innovation is sound. And so if you have a failure, it's more of a, it's not that you were, you know, thinking so far out the box that you made an assumption that failed. It was more a natural progression of of a principle that you feel strongly about, which was just the core surgical principles.

SPEAKER_02 1:05:28

Right. Uh that you said it better than me. And the using a strip of mesh to approximate tissue, that was the one big thing, not based on a human outcome, but based on rats. And I rapidly watching that was not seeing chronic draining sinuses. I wasn't seeing bowel adhesions, and patients were actually doing better than all of the other things I could have been doing. I mean, luckily I was comparing it to using a biologic mesh with a 40% SSI. Rate and a near 100% recurrence rate. So the thing I was comparing it to was so bad that mesh strips in comparison was really pretty good. But I would say going to mesh strips in humans was that one leap of faith that I made just based on intuition. But then that was, you know, taking, I was doing it very carefully and the right patient or with the retrovectus mesh behind them or a machilectomy and I was just using for an umbilical hernia. So I was being careful and I watched my results for a couple of years, and then I started doing it more and more because the results were good.

SPEAKER_03 1:06:42

And so really you're and you've been able to track your results very closely, it sounds like for a long time across a broad spectrum of surgery. And that do you think that that uh, you know, because I think in the in the community, many times people are in a very um pressure situation of you got a certain population of patients you're trying to take care of, and you're like hammering through these cases, and maybe there's a production uh drive from from within your organization and things. And so I think a lot of people don't necessarily have a good grasp of their recurrence rates in the average, in the average population, but it seems like that has been very central to your success both with your innovation and also just your success of the patients you've taken care of is knowing that and being very cautious with it.

SPEAKER_02 1:07:25

Staying at the same institution, that's really helped. And then um we have a resident research here. So I have a resident available potentially to look at cases and to do research. Um they're smart and they're in my program. And so then you know, all of this has been, you know, the residents have reviewed the cases, residents have determined an SSI, SSO, recurrence rates. Um, they're doing it now for mesh suture. So that's how I know that I was 23% for components with sutures, um, 60% for intraabdominal biologic mesh, 5% for intraabdominal proline mesh, zero for a retorectus mesh. And now we're we haven't done the long-term follow-ups for the uh mesh teacher, but for the contaminated incisional hernia, eight centimeters wide on average, we have a 92% one-year hernia free rate. So I I I can quote the numbers to you of how people are doing.

SPEAKER_03 1:08:29

Now, whenever you get you've because, like you said, you've been known for multiple things throughout the different phases of your career. And um, and kind of a lot of those phases were happening simultaneously. Sounds like it's like 2002 was uh was a year worth toasting. Um whatever, you know, in the future, whenever you're looking back on your legacy and what you've contributed to the to the world of surgery, what do you hope you're known for?

SPEAKER_02 1:08:56

Um, how to treat a painful nerve. And I I that is pretty recognized within the plastic surgery community. Um, I won uh the American the uh Association of American Plastic Surgeons Achievement Award and just before COVID in 2019 uh for my nerve work. And then um, if and when mesh suture becomes a standard of care for intraabdominal closures, then I know I've needed for the larger surgical community, and that'll be fantastic. And that will be hundreds of thousands of patients who will avoid um needing a second surgery.

SPEAKER_03 1:09:37

Yeah, I think that the you know the long the implications on that patient is enormous. The implications on the broader community and the broader society of the long-term disability associated with multiple hernia operations or hernia operation in general, uh the prevention of that, I think that that's gonna be that's like hard to even calculate. I don't think we even know what that would look like.

SPEAKER_02 1:10:04

Right. I mean, um we want to put hernia, we want to put hernia surgeons out of business.

SPEAKER_03 1:10:10

We might have to cut this part from the episode.

SPEAKER_02 1:10:16

No, but I mean prevention, you know, Bill Hope when he was AHS president. I mean, it's it is there, you know, what why do the Europeans focus on um small bites? Everyone is thinking the same thing. How is the best way to close laparotomy? But there was a recent report in Hernia of a 10.3% facial degence rate for an acute care um laparotomy, which closed with small bites back to the operating room 10% of the time. I mean, that is just unacceptable.

SPEAKER_03 1:10:46

Or not, or they don't go back. Or they don't go back.

SPEAKER_02 1:10:50

This article, they this is the University of Frankfurt, and they went back 10% of the time. And that's nice.

SPEAKER_03 1:10:56

Yeah, yeah. Or you or you just you know leave the staples in a little bit longer and cross your fingers and say we'll fix it in six months. Yeah, well, you know, I think uh yeah, I mean I think that obviously um you're not gonna find a hernia surgeon out there with everything that they're going for, that with with the way that you know, at least the vast majority of hernia surgeons I've talked to, it's really it's really patient focused, you know, trying to fix something. Because I think that um, you know, the idea of it just being a hernia, uh, that may fly for the surgeon, but for the patient experiencing it, it's usually anything but. And um, and I think that it's it's really interesting and and you know, obviously applaud your innovation. Um, it sounds like you've had a really uh you've had a really uh systematic, um, thoughtful approach to the way that you've been able to progress through your career and the things that you've been able to to uh to pursue. I you know, I think something you said that really did strike me is your the longevity at your institution has really allowed you um to to kind of grow and and progress through those different phases. And I think that's also something that's that's very unique.

SPEAKER_02 1:11:59

Well, um I was a Cubs fan and you know Ernie Banks and all the Cubs, you stayed their whole career with the Cubs. And I always I used to read these history books on baseball players, and the ones who stayed in one place always impressed me more. So in the Department of Surgery, I am unfortunately the senior guy by years in the academic faculty. But then when I started, you know, with mesh strips, and then the people around me started using mesh strips. The good care surgeons are using mesh strips, and then when my student came out, they're like, Should I use it, Greg? And I'm like, hell yeah, for sure. So then they started using it. So then um, you know, we have we've been able to do registered studies, and we're up to you know over 2,000 patients at one institution, right? And so then my research team can look at the numbers and and publish, and so all of those rely on being in one place and one time. Yeah, one institution.

SPEAKER_03 1:12:56

Well, it sounds like you've you've captured the the way that you approach your life, the way you approach your career, and then the the support from the institution. It's kind of like you've captured lightning in a bottle that that hopefully other people are able to do as well because it's it's paying off. So, you know, as we um as we come to towards the end of an episode, I always give everybody the opportunity uh to give their hernia hot take. And obviously that's uh that's a chance for you to give uh your impression of hernia surgery, your prediction for the future. I have a I have a suspicion what mine uh what it might be entail or might uh involve, but I would love for you to give us your hernia hot take if you have one.

SPEAKER_02 1:13:34

Uh my hernia hot take is don't that uh focus on suture pull-through, the tension required on closure. Uh debreedment, I didn't talk about debridement and preparing what you're gonna close to get rid of scar tissue, bringing it together with a minimum amount of total implant, and that's going to give you the best overall patient experience in terms of success of the procedure, uh lack or uh uh uh complication rate, and those complications will be of a lower magnitude by not opening up these huge tissue planes. So that's what that's what I hope sternia surgery uh moves towards.

SPEAKER_03 1:14:17

That's fantastic. I don't I don't think there's anybody that's more qualified to make that hot take than you. So we uh we appreciate your uh the the lessons that you've learned through your career so far, and we look forward for what's to come.

SPEAKER_02 1:14:29

Thank you, Lucas. It's been I hope again, it's weird. I've never done this before. I feel like I'm talking too much about myself.

SPEAKER_03 1:14:37

That's what you want. Absolutely. Okay. No, this is uh, like I said, this is a podcast about the hernia surgeon, uh not hernia surgery necessarily. I think we have there's so many avenues out there now, thankfully, that we can have the discussions about the technical aspect of what we do. Um, there's so many people that have very unique and and brilliant ways that they approach different problems that we that we come up with. And really the part about it that that I think that we're missing, um, and I hope that this is able to at least start the discussion and and other people can build on it and hopefully do better than I am. But the uh the fact that, you know, how we approach life as a hernia surgeon, how you approach life when you're doing the things that you're doing, I find that fascinating because there are definitely aspects of your career that I'm not sure I would have had the courage to do just with the my mental makeup and and and things that I think that listening to people that have accomplished a lot uh gives me something to try to emulate. So at the end of the day, this podcast is completely selfish. I am shamelessly stealing from every guest the uh the wisdom that they have to offer so I can try to you know to steal it from myself. So I really do appreciate your your willingness to come on and willingness to have the conversation and and again just thank you.

SPEAKER_02 1:15:53

My pleasure, Luke. Have a great day, and then I'm gonna go do some grocery shopping.

SPEAKER_03 1:15:58

All right. Well, this has been another episode of the Hernia Gods podcast. Thank you so much for listening, and we'll this is your mere mortal host uh signing off. Thanks.

SPEAKER_02 1:16:06

Okay.