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USA vs. UK: ASGBI Ep. 10 - The Nuanced Approach to Abdominal Wall Reconstruction · Behind The Knife: The Surgery Podcast

• ASGBI Abdominal Wall === ​[00:00:00] Hello, everyone, and welcome back to Behind the Knife. We're back with another installment of our BTK ASGBI collaborative series with our friends from across the pond. My name is Agnes Pramkmar, I'm one of the Behind the Knife fellows, a general surgery resident who'll be representing the US side, along with our UK-based co-hosts, Geeta Lingham and Elizabeth McLellan. Hi, I'm Geeta Lingham. I'm the president of the Moynihan Academy, which is a surgical trainee group in the UK. Hi, everyone. I'm Elizabeth McLennan. I'm the vice president of the Moynihan Academy and a surgical trainee here in Scotland. So today we'll be delving into the world of abdominal wall hernias, specifically reconstruction. We'll be discussing some of the differences between the two countries and how reconstruction is approached and evolved, especially with the start of robotics. And it's my pleasure to introduce Dr. Konrad Balicer for the US side for the discussion. Dr. Balicer is an internationally renowned minimally invasive surgeon. He's [00:01:00] been focused on abdominal wall reconstruction, and he currently works at Creighton University in Phoenix delving with complex hernias, and frequently publicizes his teaching education videos on YouTube. Thank you, Agnes and it's my honor to introduce Dr. Akash Mehta from the UK side. So Mr. Mehta is a consultant colorectal surgeon at St Mark's Hospital in London in the UK. He is interested in intestinal failure and rehabilitation surgery. He is also the lead for the region's abdominal wall multidisciplinary team, and has successfully established a minimally invasive abdominal wall surgical program. Thank you very much, Geeta, for the introduction, and thank you very much for having me. Of course. So to just start off, how would you each define abdominal wall reconstruction, and what are the some of the common procedures that you each perform? So speaking for myself I believe abdominal reconstruction is a compilation of different approaches in order to fix complex hernias, whether that's gaining access to the extraperitoneal plane, whether it's [00:02:00] doing component separations to be able to reconstitute linea alba, return the muscles back into the midline. Yeah, I agree with that. Something more than just placing mesh. I was just gonna say you know, just slapping a mesh onto something probably doesn't constitute an abdominal wall reconstruction. I think if you are to be pedantic about it, you'd say it needs to involve some form of myofascial release of some description to aid closure reinforce that with a mesh of some description, ideally extraperitoneal mesh. Okay. And we've heard a bit about your backgrounds but have either of you had any plastic surgery training? Is that a- an offensive term to ask in the abdominal wall reconstruction world? I always tell my patients I, I'm more of a functional surgeon than a plastic surgeon. I was never good at that. I often work with my plastic surgery colleagues. The onus is up to them to making them look nice a- and pretty. The onus of responsibility that I carry is to be able to put them [00:03:00] back together in the best way possible with the resources that I have Yeah, I've not had any formal plastics training. I've picked up pearls of wisdom and snippets of wisdom here and there from friendly plastic surgeons when we've operated together. But you know, just like Konrad says, it's about restoring the function and the anatomy of the abdominal wall. And I must say with notable exceptions, mostly the techniques which we would employ for, again, coming back to the definition of abdominal wall reconstruction, are I think more in the realm of general and dedicated abdominal wall surgeons rather than amongst plastic surgeons. I think expertise and experience is growing amongst the plastic surgical community, but certainly in the UK, it's not really the domain of them to, do things like TARS and everything like that. What percentage of your cases would you say are done jointly, both if we start off with the UK, gosh I think a vast minority, so probably less than fi- definitely less than 5%. [00:04:00] Yeah. I typically only really get the plastic surgeon involved if I expect a major soft tissue correction, excision whatever you want to call it. You know, people who've got a major loss of domain hernia where you can be left with a lot of skin excess, which is just gonna be pulling on your repair. If there's a lot of soft tissue damage then I might, but I must say that the vast majority of patients, especially the ones where I do a minimally invasive abdominal wall reconstruction, I don't actually involve a plastic surgeon because even if they have a skin excess, quite often that will remodel to a large degree, and then, you know, the ones where it hasn't remodeled to a degree that they're satisfied with, they can then separately see a plastic surgeon. And is that different in the US? I think about 5 to 10% of my cases are, are done open, and typically, the open procedures that I do are combined with abdominoplasty or panniculectomy done with a plastic surgeon, so about 5 to 10% for me. I know, Dr. Ballester, you use Botox as well, but that's just something that you do under your purview, [00:05:00] right? You don't necessarily ask the plastic surgeons to help with that? No. You know, before when I was in private practice, the only ones that held Botox were plastic surgeons, so I would often ask a plastic surgeon friend of mine who was a co-resident should I say to do the Botox. That was logistically very difficult. It typically wasn't covered by insurance. The patients typically had to pay. When I transitioned to academic surgery we now ask our radiologists to inject Botox in patients typically with loss of domain big hernias, multiply recurrent, noncompliant abdomens. That's been a nice transition in that it's typically covered by insurance now. I'm not sure of the difference. But I would imagine that 15 to 20% of my patients are Botoxed. I tend to use it a lot. And then speaking about, patient factors, when you're looking at a patient's chart or talking to them, what are the most important factors that influence your decision-making on what type of case you'll pursue if you would do it open or robotically or [00:06:00] laparoscopically? It really depends. Obviously I have a strong emphasis in minimally invasive surgery with the use of the, the robotic platform. Like probably 90% of my cases are done minimally invasive. But in the event that they have dystrophic skin or, I feel they would benefit from a panniculectomy that would be done open which again, is about 10% of my practice currently. So my practice is slightly weird in the sense that I do a lot of, kind of, just abdominal wall pathology, but I also do a lot of abdominal wall pathology in the context of major intestinal pathology, so, you know, enterocutaneous fistulae and similar. Which means that those are the cases, even though I've done a few minimally invasively, again, with the use of the robotic platform, like simple enterocutaneous fistulae, et cetera, with a simple abdominal wall. Those are primarily the cases I do open, and if I were to put those to one side, then I think my, kind of my isolated, pure abdominal wall pathology, more or less similar. The vast majority I'm now doing minimally [00:07:00] invasively with the robot, especially as I've got more confident and comfortable with it. I tend to go a bit further every time, and I kind of say, "Well, listen, I'll at least have a..." Well, have a go sounds a bit belittling, but I'll dock the robot. I'll see how far I can get. And I think, you know, people ask me sometimes, what's the difference between conventional minimally invasive laparoscopic surgery versus robotics? And I think one of the thing is that you can get far further with robotics. It's far more akin to an open operation without a big incision than otherwise. So- Yeah ... yeah, and I think if you think about patient factors, I think the other thing to bear in mind is, what have they had done already, which planes have been opened. I'm fairly strict about trying to get a hold of surgical notes and operative notes if they've been operated elsewhere, just to kind of get an idea which planes have been opened. I think fortunately a good proportion of surgeons don't necessarily, as a routine or as their first go, go into the retrorectus or retromuscular space. So quite often for me, that's a plane which [00:08:00] been untouched, which makes me quite happy. I'm always slightly less happy when it's already been opened. But you know, I still, we still cope, I think. And I think the other thing is, you know, patient factors is also about optimizable and addressable risk factors, isn't it? If somebody is actively smoking and is obese with better-controlled diabetes, that would, that would skew my decision-making even if I were to consider an operation in a completely different way. You know, kind of like a burn no bridges type approach versus a, a formal abdominal wall reconstruction. That's interesting. So, essentially take home point there is if you're not gonna do a proper repair, don't go into the retrorectus space. Nope. Leave it for someone who wants to- Yeah ... and is good at it. Of course. And just thinking in terms of, like, optimization of patients, so I think the US and the UK does slightly differ here. So from a UK perspective, are we getting these patients through? Is there a long waiting list? Are they prioritized? How does it work in terms of waiting lists? [00:09:00] So things are changing. I think we're in a very exciting time, at least as far as the UK is concerned, where I think a lot of colleagues are recognizing that this is not something they can just do on the side, like, "Oh, it's just a hernia. I'll slap them on at the end of my operating list, and let's kind of, you know, fast-track them through pre-op." These are proper, with inverted commas, operations which require work-up, require optimization. Because if done properly, you only really get one go at it. It's really difficult to do a redo TAR or a redo, retrorectus dissection. It's possible and I unfortunately or fortunately I do a lot of them, but it's not fun. And so you really want to get it right the first time. So I think that's changing now in the UK, where we're transitioning from this thing where, a lot of old school, old generation surgeons are like, "Well, I'll just do a hernia as well." They're like, "No, this probably needs to go to a center where they just need to, have access to things like prehabilitation, Botox and a multidisciplinary meeting where we, talk through all of [00:10:00] this, a specialist clinic." I think all of that is really, really important. I would echo what Akash has said. I think there's been a growing interest in hernia repair, and I think a lot of that is stems from the adoption of the robot i- in being able to do minimally invasive things that weren't widely done before. I think the incorporation of minimally invasive abdominal wall reconstruction into the armamentariums of surgeons around the world whether it's good or bad in my opinion, minimizes the requirement for that, you know, BMI under 35 no smoking, HbA1c under seven, even though I follow those guidelines. But that being said people have asked me what has changed in my practice and how I've become a better surgeon in the last five to 10 years and that's understanding them in clinic, understanding optimization better, understanding the goals of hernia repair and abdominal wall reconstruction and getting them to buy in that they need to prove to me they're [00:11:00] willing participants in their recovery process. You know, convincing them that hernia is a lifelong disease a- and that hernias can come back. They can be complicated years after the index repair, either in the form of chronic pain and/or recurrence. And I agree with Akash, I think people have a better understanding of hernia repair and the pathology and it's not just a hole to, patch with a piece of mesh. There should be a lot more consideration to that which is kind of nice because the specialty is certainly evolving quickly. One thing I would say is that I think the introduction of robotics is a great thing, but it's also s- a slightly double-edged sword because it's opened up abdominal wall extraction to a whole group of surgeons who are not necessarily familiar, I think, with the anatomy or being able to recognize when they're in the wrong plane. And, you now got a generation of surgeons whose first exposure to abdominal wall surgery is robotic abdominal wall surgery. And they kind of start embarking on, [00:12:00] you know, E-type restopas, TARS robotically without necessarily having done undoubtedly the kind of training exposure Conrad and I have had in terms of being able to identify when you're in the right plane, when you're in the wrong plane. And I think that's a slightly double-edged sword, and that's probably one of the risks we're gonna have over the next few years. Oh, yeah, I totally agree with you Akash. You, you know, this whole boom, the start of robotics and how that ballooned here in the United States the field was pretty much born on YouTube, right? Yeah. It's surgeons releasing videos on YouTube and people copying, and that's been a controversial topic, especially with that New York Times article that came out a couple years ago talking about how patients are being injured that hit piece that New York Times wrote. You'll be hard-pressed to, to come to read that story and say it's 100% false. So again [00:13:00] notably, I speak at congresses and congresses all around the world my tune has changed into the more about the considerations of it, more about the problems of being on the wrong plane, more about education of what is the right plane educating people on anatomy of the abdominal wall because you're exactly right. You know, there's residents or, experienced surgeon watching a video. They have a robot in their hospital, and all of a sudden they're suturing abdominal walls and cutting different layers without the the basis and the foundations to understand what that actually means. So on the note of training actually, so I understand the point that you're saying about robotics coming about and maybe people that aren't experienced doing things. So far in my training I would say I've only had exposure to abdominal wall reconstruction when a particular boss or someone that I'm training with has an enthusiasm, but it's no, there's no set training pathway. So if I want to do it, I just have to seek out mentors and senior surgeons that enjoy [00:14:00] doing that. Do you think it's something that as trainees we should be looking at early on? Do you, how do you think training should be dealt with? Difficult, isn't it? I think now, at least in the UK, there are a few dedicated or less dedicated abdominal wall fellowships arising. Some of them not purely abdominal wall, but like intestinal failure and abdominal wall. That's kind of how we've, sold our fellowship here at St Mark's that it started off as a purely intestinal failure fellowship, and now more and more we're getting people interested primarily in abdominal wall components of that, and that abdominal wall component has transitioned quite substantially from big open abdominal wall surgery to minimally invasive. And I think that's probably the route to travel. It's quite difficult, and that's mainly because of the way people operate and specialties operate in this country. I think it's really difficult to set up a dedicated abdominal wall fellowship in the UK because there's no such thing as a dedicated, at least in the NHS, there's no such thing as a [00:15:00] dedicated abdominal wall surgeon. It just doesn't exist. It does exist to a certain degree on the continent, continental Europe. It exists the United States. But, you know, as long as there's not, a dedicated group of surgeons across the country who dedicate themselves only to abdominal wall surgery, it's gonna be really difficult to offer a dedicated fellowship. I think that being said, there's more and more opportunity for senior trainees, junior consultants, and attendings to get that exposure, you know? To get themselves onto what I would consider to be proper courses, masterclasses, cadaver workshops where they get that, that anatomy, get that exposure that they know what to look out for, and then get themselves going with informal proctorship or even formal proctorships with, starting with simple abdominal wall and then progressing, and that's nearly separate to whether it's an open or robotic. It's about understanding those planes. I, I totally agree. The abdominal wall surgeon that's [00:16:00] becoming a specialty here in the United States with increasing momentum driving towards that. And at the end of the day, it kind of makes sense, you know. The people that are doing it all the time probably should be doing it. We learned that from Whipples in- the United States where we went from everybody's doing a Whipple out of training to Whipples are kind of reserved now for only specialized centers that do it often. It... When I went transition from private practice into academic surgery where I was training residents on a consistent basis, a- and I made that transition in 2019 my entire goal... Because in 2019, the flavor at that time were residents were losing cases- To inexperienced robotic surgeons in academia because those surgeons were reserving the robot for the most difficult of cases. They would do one to two a month. They would never get past their learning curve. The byproduct of that, the, junior and senior residents were losing cases they otherwise would've done open or straight [00:17:00] stick laparoscopy and relegated to being bedside assists. And I saw that everywhere in the United States. So that was my challenge when I decided to go into academic surgery, was my challenge was to get the residents in the forefront, get them out of bedside, get them onto a dual console that we have here and get them to operate. You know, I always say I never consider myself intelligent, but I'm very intentional in pretty much everything that I do. And that's when I released my resident and I compilation in YouTube, where I would showcase residents doing cases and post their video and bring it out to the world to say, "Hey, residents need to be operating. They can't be exchanging instruments bedside." So here at Creighton, we have an abdominal wall surgery service. We pretty much only do hernia repair and abdominal wall reconstruction. And we get our residents in from their first year of all the way up to their fifth year consistently on the robot, [00:18:00] which I think is a little bit different than other places here, but that's how the trend is moving for sure. I have been a bedside assist at a long robotic case, so it's very nice to hear someone talk about as- The irony ... yeah, no, as registrars we should maybe be doing a bit more on the consoles and learning a bit more. Do you think that's been something that's been taken on board by your colleagues as well? Yeah. You know, it's funny, when I initially came here, they were bedside assists largely. I'm again, not intelligent but intentional, and I think rising tide floats boats. So if, in Ballaster's room, if an attending sees the resident operating, you know, that, says, "Okay, well, I better get the resident to operate." I think Agnes would agree the residents here at Creighton get a ton of robotic experience. You know, it's honestly rare to see straight stick laparoscopy now 'cause everyone's doing the robot. All the attendings are preferring the robot, and this is for not only for hernia repair but really for [00:19:00] every general surgical pathology, including acute care surgery. You just don't see much laparoscopy anymore. There's byproducts to that. And that's kind of the big controversy in the United States right now. There's been a few articles released saying, "You know what? We need to back up. We need to not train people in doing robot. We need to go back to straight stick laparoscopy, make sure that they're well attuned to be able to offer that." And yeah, that's ideal. I did a minimally invasive laparoscopic fellowship when I graduated my residency and I feel blessed that I have that skill set in my back pocket. But the reality is if all the attendings are doing it robotically residents are hard-pressed to find any straight stick laparoscopy case here in the United States. So that's kind of the way US is trending. It's exciting to see that robots is starting to emerge in the UK, which has been kind of a slow process over there. But ultimately it's kinda hard to stop that fast moving train, Yeah. I think UK is still in that kind of period where a [00:20:00] lot of consultants are still getting their own... are working on their own robotic exposure. I'm not talking just about abdominal wall, but also, cancer resections, IBD, stuff like that. And that's, I think, the detriment of the training of fellows and residents. I notice that myself, I think as time goes by I'm becoming more confident and comfortable with, robotic abdominal wall, which is my, I think the only thing I really do robotically in good volumes, to the point that it's only really been the last year, year and a half that I'm letting my fellows do more and more. And the problem is that you then also realize that they've had so little robotic exposure and training because of their, whatever hospitals they worked in, their own consultants doing a lot of the robotic stuff themselves. And it's got to the point that, even I tend to even do relatively simple abdominal wall cases like, primary umbilical hernia repairs. I tend to do those robotically now as well, because those are fantastic training opportunities as well for fellows. You get the basics [00:21:00] of virtually all of the aspects of it which works quite well. But it's a slow process. We're certainly a little bit behind the US in that regard, but hopefully we are getting there. And like Tandra said, it's a... You can't stop it. You know, it would be great to have a group of surgeons who can do something open as well as laparoscopic as well as robotic, but it's just, it's unstoppable, isn't it- Yeah ... to go that robotic- Absolutely ... trend. Yeah. I, I remember the general surgeons back before my time, they did everything, right? They did vascular surgery. Yeah. They did breast surgery. They did Whipple's. They did hernia repair. That doesn't exist i- in the United States anymore. No. You rarely- No ... find that unless you're working in rural medicine. That was one of my misgivings to change to academic surgery. But prior to when I was in private practice I did everything. You know, I did minim- operations foregut, hindgut, solid organ and hernia repair. You know, now all I see are big, nasty, recurrent incisional hernias. Thank God, Akash, I'm not a leader of [00:22:00] an intestinal failure unit. That just sounds so sad to me you know, to be having to deal with enterocutaneous fistulas a lot. I talk with Professor Mara Burmeister all the time, and I go, "What are you thinking doing this pract... " She would show me pictures and videos of what she's doing, and I was going, "That's just not very fun to me." But so, kudos to you for dealing with that patient profile. Yeah, it's challenging, but it's really good fun, and it really keeps you on your toes when it comes to decision-making and, you know, postoperative complications and everything. I'm still learning on the job, you know, every, every day- Yeah ... every case you do, especially these kind of intestinal failure cases. Because every, every case poses its own challenges and everything. And also about, you know, how far do you go, right? People ask me, "Do you always do a single-stage fistula repair and abdominal wall recon?" I say, "Well, there's no such thing as always," right? Yeah. It depends on the individual case. And learning to get that choice correct for that patient in that moment in time [00:23:00] is I think a fun but also challenging part of the job. Yeah, I think that really incorporates the , the science of what we do. Yeah. The art of surgery in that there's not just one fix for everything, right? Whether you stage it- That's it ... whether you prehab, how much do you prehab, how much do you optimize, when a patient is ready. I agree with you. That's what makes it fun, because it brings the art of surgery back into play. You know- Yeah ... it's not like, okay patient has colitis, you take out the gallbladder right? There's a lot of decision-making that goes into it. There's a lot of expectations that you need to set for the patient. The patient then needs to understand what they need to do in the preoperative period. So, you really form a relationship with the patients, but the benefit of that is to get them to an entirely different place. I think the understanding of what we do has been crystallized you know, by a good friend, mentor of mine who's considered the GOAT of hernia repair here in the United States, that being you know, Professor Todd [00:24:00] Hennipifd, who breaks it down very simple. I'm a quality of life surgeon. Yeah ... my goal is to get you from where you can't do much, you can't hold your grandkids, you can't play with your grandkids 'cause you're so scared your hernia's gonna blow up or something and get them to an entirely different place, you know? Which is different than other surgical pathologies right? Yeah, that art of surgery really makes that fun and compelling. And that's what people are seeing across the United States which is why abdominal wall surgery, hernia repair is in a totally different place now than it was just 10 to 15 years ago. Yeah, interesting to hear, isn't it? Because I think if done correctly by getting patients to engage with prehab and, you know, changing their risk factors and everything, the benefit to their life and their quality of life exceeds the benefit from just fixing the anatomy and the function of the abdominal wall, right? Because we, what we see is consistent changes, right? Once they've lost the weight, most of them continue to keep the weight off. Once they've stopped smoking, most [00:25:00] of them will continue to not smoke, and their diabetic control will be far better. So the benefit to them, to their life, their outlook, their health, their wellbeing far exceeds just a hernia repair. And I think that's, you know- Totally ... one of the important things when you're talking about quality of life surgery is that we actually are in a privileged position to actually, you know, improve their overall health In, trying to get them to a hernia repair, and I think that's a, that's an immensely important and privileged position to be in 100%, Akash. So just to give you a little bit of background, I was trained by Alfie Carbonell and Will Cobb in Greenville, South Carolina. That's where I did my minimally invasive surgery. They were both fellows of Todd Heniford. And large part of my training was lap IPOP, bridging lap IPOP- Mm big dual mesh, you know. No doing it laparoscopically, we made no attempts at reconstituting linea alba, returning the muscles back to where they should be. And, and I consistently questioned myself [00:26:00] even after fellowship when I was doing these lap IPOPs on, you know, 15, 20 centimeter wide defects and bridging it with big pieces of mesh. I would going, "What am I, what is the goal of what I'm doing?" Mm. I couldn't understand it. Am I just preventing a, an incarcerating event? You know, because their quality of their lives weren't better . And I saw them in the office. They still had a bulge. They didn't like the bulge. A lot of them had an element of core dysfunction. Certainly acute and postoperative pain after lap IPOP, transfascial sutures, circumferential tacks. I would always advise my patient this is probably the only minimally invasive procedure that hurts more than its open counterpart. And I think I was true there. That was really the impetus of what made me change, you know? That's what made me search for something else which in large part is the reason why robotics is so, highly adopted now. Do you think the robot has spread so much in the US because of the whole privatization of healthcare I don't think so. I think [00:27:00] people recognized that this was a tool, an evolutionary tool that had allowed us to do laparoscopy perhaps better or perhaps more comfortable, perhaps maybe easier. The robotic platform is easier than straight sick laparoscopy. Back in 2012, I remember I was first trained my first cases were two gallbladders elected gallbladders. They weren't particularly easy. I was proctored. We had a required proctoring of cases. And, and back in that time, there were no general surgeons who were proctors or rare. Yeah. So my proctor was a gynecologist from the East Coast who trained me in doing a gallbladder, and he said he hasn't seen a gallbladder in a number of years right? Since he was a resident, maybe rotating in general surgery. But right after those two gallbladders, I called my... This is how naive I was, right? I called my, I called my scheduler. I said, "Everything that was booked laparoscopically, book it as a [00:28:00] robot." And the hospital was like, "What? You know, you're doing gallbladders, you're doing, acute care surgery." We had the benefit at that time, we were so busy electively, so the community hospitals that we worked in, my partner and I we held a position of strength in that we were making their ORs very busy. And in the US, I'm not sure how it is in the UK the OR is the moneymaker of the entire hospital. And I quickly transitioned to where I was not doing any straight sick laparoscopy you know, really 2014, '15, '16 where everything was done robotic. And I'm saying everything, like bowel obstructions, gallbladders, perforated appies, colons. And then obviously in hernia repair But hernia repair was the kicker. Yeah. That's, that's where the, that's where the surgeon said, "I can't do that with straight sticks." Yeah. So... So my, I did my first, I started off with mini-invasive abdominal wall reconstruction with three [00:29:00] laparoscopic attempts. So there was an E-TEP, there was a unilateral TAR. What year was that, Akash? Oh gosh, that was, 20, 2022. Mm-hmm. And after those first three, I was like, "I'm never gonna do this, this nonsense again. I'm never gonna do this laparoscopically, like, ever. It's just, it's just not a thing, right?" Yeah and I just transitioned to robotic, even just for, my poor back and lumbar spine sake. It's just- Yeah ... incredibly uncomfortable doing those cases, Incredibly ... with straight stick laparoscopy, and it's unnecessary now. And if you think about what is it that the robotic platform brings, I think it's multiple things, right? It's the dexterity. It's far more akin to open surgery, the movements you do and the ease with which you do them, but it's also just the visualization. You don't get that visualization in any other way. As an example we all learn in, when you think about the anatomy of the abdominal wall, that there is an ex- when you do a TAR, there's an extra peritoneal plane, but there's also an extra transversalis fascia plane. But [00:30:00] I saw that for the first time properly and clearly when I started doing robotic TARs. Yeah. Totally. And that's actually changed how I do that same operation open. I go looking for that plane. And I think that's just an example of, the robot- And I wouldn't be, have been able to really acknowledge that or recognize that if it just stuck to straight stick laparoscopic surgery. 100%. You see microfascial planes that- Yeah ... are now pretty well described. You know, I was trained how to do lap-tap inguinal in, in fellowship. That's pretty much what I did for my first two years out of practice. I never saw those planes. I never dealt with those planes. My thing was open up the space, reduce the sac, and place mesh. But now there's strategies. , The visualization of the robot has provided an educational foundation for our better understanding of the abdominal wall. Yeah. Absolutely. I think what you mentioned about using what you're learning from the robots to influence the open cases, I think that's important as well. So- Yeah ... we [00:31:00] just wanted to end with a few rapid-fire questions between you two, so first one being, what is the most underrated paper in hernia surgery? Critical view of the myopic tenia orifice. I honestly think that is the most important paper that has been produced in the last 10 years in hernia repair Yeah, all of your residents have to memorize it before we show up for our- All of them have to memorize . Yeah. And if, if you don't mind, if I can just talk about this. Yeah. And that's kind of the funny thing. Surgeons generally speaking, traditionally have been guided by peer-reviewed peer-reviewed journal articles. That, that typically guided us to, of what we should do and what we shouldn't do, right? We would look for that randomized, that magical randomized control trial to tell us, "This is the way to do it, this is the way not to do it." That's kind of changed in hernia repair, in my opinion. There's so many, there's papers, there's so many papers that are being produced out there in the wild but, if you look in the United States in terms of the robotic adoption, there's really not a single paper a [00:32:00] sentinel paper that said the robot is better than any other modality, either laparoscopic or, or open, yet the adoption continues to climb i- in the robotic framework. So, I think hernia repair is very dependent on the resources that you have, the skillsets that you have as well as the training that you've been brought up with i'm sorry, I know that's supposed to be a quick shot, but I wanted to get that in there. Well, I'll add to that and say that, it's interesting that surgeons tend to always look for, you know, this non-existent randomized control trial in something or the other, but then when there is a trial, they ignore it if it's uncomfortable for them. Exactly. Like for instance, the small- Exactly ... bowel closure, right? 100%. I don't know how it is in the U- Totally ... I don't know how it is in the US, but I, you know, in the, one of the things which I really want my fellows to go away with, to be able to close a, a laparotomy wound properly, like not with a loop- Yeah PDS, great big stitches and, you know, strangulate the muscle. Yeah. And yet the adoption in the UK is still dismal, and that's despite the fact that this is [00:33:00] one of the things where there's actually randomized control evidence. So, you know, even if it- Yeah ... is there, then they tend to ignore it anyway because it's an uncomfortable truth. Totally. 100%. Yeah. Mm. Okay, next question. Most overrated innovation? you can say the robot. Well, I was actually gonna say, in the wrong hands, the robot. Because I think the robot, there's a risk, like I was saying earlier, there's a risk that people start focusing on the tool rather than the actual procedure, right? It's still really important to be able to do a retrocolic dissection properly. Whether you do it straight stick, there's a few people I know off the top of my head who could probably do a good straight stick laparoscopic tar, reef stopper, whatever. Very few. But whether you do it open, robotically, laparoscopically, the focus should be on that anatomy and getting that procedure done correctly. And there's a risk that the, that's in, that in the r- in the term robotic abdominal wall reconstruction, the [00:34:00] robot gets all the emphasis rather than the abdominal wall reconstruction. I'd probably say that. I think the other slightly overrated innovation is , biologic meshes. There's now such a push from industry that thou shalt use an a biologic mesh. The preponderance of evidence is still that the best long-term outcomes in terms of recurrence rates are still achieved in non-contaminated abdominal wall reconstruction with a simple barbed or synthetic non-absorbable mesh. And whilst it probably makes sense in certain patients and that, especially now they're leaving some of the, some of the decision making, the patient voice is important and all of that, at the end of the day, just saying, "I'm gonna use this expensive mesh because it's expensive so it must be good," just I think is doing some patients a disservice. The next one I have for you both is one operation that every resident should master before graduating. Closing a laparotomy properly There you [00:35:00] go. Yeah. Agree. But if you're talking about hernia repairs, I would say a proper Reef Stopper yeah. A proper lap angio would help too, whether it's done robotically or with straight sticks. I think that's it. And open angio. Again, not a quick fire, but one of my biggest regrets is that I didn't learn how to do open angio very well. Interesting. Okay what advance are you excited about in the future? I'm excited about the emergence of competitive robots to be able to increase its adoption worldwide, not only for patients, but also for surgeons all around the world. Yeah. I was gonna say the same thing. I think the fact that they're now competing upcoming robotic platforms which are also sometimes more cost-effective, opens up, whole robotic surgery platform to patients and surgeons nearly regardless of income and financial status for the institute or their country, and I think that's really exciting Thank [00:36:00] you. Do you guys know Neil Smart? He was, an amazing friend of mine. Um, yeah, This is a great opportunity to just give a shout-out to Neil, and the fact that he was always so open and welcoming to anybody to share his knowledge and his insight and his experience, he never said no to anybody if they kind of invited themselves over to his unit, and he'd always make sure that you had a good time, took you out for dinner. But also he was just, he was such an open person and just so gracious with everything he's done and so humble. So you know, and I think he is being and will continue to be sorely missed. And the fact that two surgeons from either side of the pond are speaking fondly of him and know him so well, I think says a lot about his legacy. For sure. That's such an enormous loss. Yeah. Rest in peace, my friend. Thank you both for your invaluable time and for sharing those really unique insights with us. I've enjoyed hearing about your practices in both [00:37:00] US and the UK. Thank you. And thank you- Thanks, Jill ... all of our listeners for tuning in. Be on the lookout for more of our episodes in the future, and remember to always... dominate the day. Dominate. Dominate the day together. Dominate the day, Dominate the day. Dominate the day. Dominate the day dominate the day. Dominate the day. Dominate the day.