Behind The Knife: The Surgery Podcast

Expert Dr. Dan Hashimoto discusses the role of AI in surgical education. Topics include deep learning, collaboration between surgeons and engineers, ethical considerations, research methodology in AI, and the importance of AI education in medical training.

The Fellowship of the Snow kept it interesting this year…both on and off the slopes!  On this episode, Patrick Georgoff discusses the Western Trauma Association’s updated resuscitative thoracotomy algorithm with Ron Tesoriero, the results of a WTA multicenter trial exploring chest tube irrigation for the prevention of retained hemothorax with Thomas Carver, and prehospital blood administration with Juan Duchesne.   ** Algorithms and papers are pending final review and are therefore not available to link to this episode.   Ron Tesoriero, MD: Associate Professor of Surgery, Director of the Acute Care Surgery Fellowship, and Co-Director of the SICU at UCSF. Thomas Carver, MD: Associate Professor of Surgery, Director of the Acute Care Surgery Fellowship, and Senior Medical Director of Critical Care Services at the Medical College of Wisconsin.   Juan Duchesne, MD: Professor of Surgery and Chief of Trauma and Acute Care Surgery at Tulane university.    Resuscitative Thoracotomy: The Who (Episode 475): https://app.behindtheknife.org/podcast/big-t-trauma-series-ep-14-ed-thoracotomy-the-who  Resuscitative Thoracotomy: The How (Episode 476): https://app.behindtheknife.org/podcast/big-t-trauma-series-ep-15-ed-thoracotomy-the-how Innovation Lifeflow (Episode 642): https://app.behindtheknife.org/podcast/innovations-in-surgery-lifeflow We now have over 725 episodes!  The easiest way to find specific topics or episodes is on our website https://app.behindtheknife.org/home or on our new Apple/Android app.  You can search or browse by topic, podcast series, etc., making it much easier to navigate than podcast players.   iOS: https://apps.apple.com/us/app/behind-the-knife/id1672420049 Android: https://play.google.com/store/apps/details?id=com.btk.app PREMIUM BUNDLE: https://app.behindtheknife.org/bundle/95 Please email hello@behindtheknife.org to learn more about our premium bundle and institutional discounts.  Premium Bundle Includes: General Surgery Oral Board Audio Review Trauma Surgery Video Atlas Colorectal Surgery Oral Board Audio Review Surgical Oncology Surgery Oral Board Audio Review Vascular Surgery Surgery Oral Board Audio Review Cardiothoracic Surgery Surgery Oral Board Audio Review

In this episode of Behind the Knife the vascular surgery subspecialty team discusses a few case scenarios of patients with dialysis associated hand ischemia (or steal syndrome). Although a rare, steal syndrome can be detrimental to patients with end stage renal disease and result in not only risk of losing dialysis access but even their limb.  What options do you have to fix this problem? In this episode, we will cover the who is at risk of this, and what options you have to fix it. Hosts:  Dr. Bobby Beaulieu is an Assistant Professor of Vascular Surgery at the University of Michigan and the Program Director of the Integrated Vascular Surgery Residency Program as well as the Vascular Surgery Fellowship Program at the University of Michigan. Dr. David Schectman is a Vascular Surgery Fellow at the University of Michigan Dr. Drew Braet is a PGY-4 Integrated Vascular Surgery Resident at the University of Michigan Learning Objectives - Review high-yield topics regarding hemodialysis access - Understand the incidence of and the relevant risk factors for dialysis associated steal syndrome - Review the spectrum of presenting symptoms and relevant workup for dialysis associated steal syndrome - Understand surgical treatment options for dialysis associated steal syndrome References Please review the journal article below for helpful pictures and depictions of the operations we describe in this episode. - Al Shakarchi J, et al. Surgical techniques for haemodialysis access-induced distal ischaemia. J Vasc Access. 2016 Jan-Feb;17(1):40-6. https://pubmed.ncbi.nlm.nih.gov/26349875/ Other helpful references - Kordzadeh A, Parsa AD. A Systematic review of distal revascularization and interval ligation for the treatment of vascular access-induced ischemia. J Vasc Surg 2019; 70:1364. https://pubmed.ncbi.nlm.nih.gov/31153703/ - Huber TS, Larive B, Imprey PB, et al. Access-related hand ischemia and the Hemodialysis Fistula Maturation Study. J Vasc Surg 2016;64:1050. https://pubmed.ncbi.nlm.nih.gov/27478007/ - Sidawy An, Spergel LM, Besarab A, et al. The Society for Vascular Surgery: clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access. J Vasc Surg 2008; 48:2S. https://pubmed.ncbi.nlm.nih.gov/19000589/ ***Fellowship Application - https://forms.gle/5fbYJ1JXv3ijpgCq9*** Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

Join BTK eduction fellows, Drs. Nina Clark and Jon Williams along with guests Drs. Sharmila Dissanaike and Paula Ferrada for a discussion on whether it’s time for a paradigm shift toward a circulation-first approach to trauma resuscitation. Hosts: Nina Clark, MD and Jon Williams, MD Guests: Sharmila Dissanaike, MD - Texas Tech University Health Sciences Center, Lubbock, TX Paula Ferrada, MD - Inova, Fairfax, VA References: Ferrada P, Dissanaike S. Circulation First for the Rapidly Bleeding Trauma Patient-It Is Time to Reconsider the ABCs ofTrauma Care. JAMA Surg. 2023 Aug 1;158(8):884-885. doi: 10.1001/jamasurg.2022.8436. PMID: 37195675. https://pubmed.ncbi.nlm.nih.gov/37195675/ Ferrada P, Ferrada R, Jacobs L, Duchesne J, Ghio M, Joseph B, Taghavi S, Qasim ZA, Zakrison T, Brenner M,Dissanaike S, Feliciano D. Prioritizing Circulation to Improve Outcomes for Patients with Exsanguinating Injury: ALiterature Review and Techniques to Help Clinicians Achieve Bleeding Control. J Am Coll Surg. 2024 Jan 1;238(1):129-136. doi: 10.1097/XCS.0000000000000889. Epub 2023 Nov 28. PMID: 38014850; PMCID: PMC10718219. https://pubmed.ncbi.nlm.nih.gov/38014850/ ***Fellowship Application - https://forms.gle/5fbYJ1JXv3ijpgCq9*** Please visit https://app.behindtheknife.org/home to access other high-yield surgical education podcasts, videos and more. If you liked this episode, check out our recent episodes here https://app.behindtheknife.org/listen

Explore the debate over one versus three years of adjuvant imatinib treatment for gastrointestinal stromal tumors, highlighting improved recurrence-free and overall survival with longer therapy. Dive into the impact of targeted therapies on GIST care, discussing variations in therapy durations and implications on survival rates. Compare US and European healthcare systems in managing GISTs, and gain insights on factors influencing recurrence risk, treatment response, and therapy resistance in GIST patients.

Though relatively rare, lateral abdominal wall hernias present a unique challenge to surgeons. Join Drs. Ajita Prabhu, Lucas Beffa, Sara Maskal and Ryan Ellis as they talk through their approach to these difficult cases.   Hosts:   · Ajita Prabhu, MD, Cleveland Clinic, @aprabhumd1  · Lucas Beffa, MD, Cleveland Clinic, @BeffaLukeMD  · Ryan Ellis, MD, Cleveland Clinic, @EllisMD2020  · Sara Maskal, MD, Cleveland Clinic  Learning Objectives:   · Review anatomy of lateral abdominal wall hernias  · Review pitfalls of operating in the retroperitoneum  · Review surgical approaches to repair defects based on algorithmic assessment   References:  · Montelione KC, Petro CC, Krpata DM, Lau B, Shukla P, Olson MA, Tamer R, Rosenblatt S, Rosen MJ, Prabhu AS. Open Retromuscular Lateral Abdominal Wall Hernia Repair: Algorithmic Approach and Long-Term Outcomes at a Single Center. J Am Coll Surg. 2023 Jan 1;236(1):220-234. doi: 10.1097/XCS.0000000000000419. Epub 2022 Dec 15. PMID: 36106747.  https://pubmed.ncbi.nlm.nih.gov/36106747/ · Beffa LR, Margiotta AL, Carbonell AM. Flank and Lumbar Hernia Repair. Surg Clin North Am. 2018 Jun;98(3):593-605. doi: 10.1016/j.suc.2018.01.009. Epub 2018 Mar 12. PMID: 29754624.  https://pubmed.ncbi.nlm.nih.gov/29754624/ ***Fellowship Application - https://forms.gle/5fbYJ1JXv3ijpgCq9*** Please visit https://app.behindtheknife.org/home to access other high-yield surgical education podcasts, videos and more. If you liked this episode, check out our recent episodes here https://app.behindtheknife.org/listen

In this podcast, they discuss in-flight medical emergencies, including common events, equipment on board, and regulations for providing medical assistance. Guests include Dr. Thomas Doyle, who shares insights from his experience as the medical director for STAT-MD. They also explore the complexities of managing emergencies at high altitudes and the importance of teamwork and collaboration during crises.

You have a patient referred to you for a history of anal dysplasia and found to have an anal lesion on colonoscopy. How do you evaluate this? What are the risk factors? How will you perform surveillance afterwards? Does everyone need HRA? Tune in to find out! Join Drs. Peter Marcello, Jonathan Abelson, Tess Aulet and special guest Dr. Lisa Breen as they discuss high yield papers discussing Anal Dysplasia.  Learning Objectives 1. Describe the different types of anal dysplasia and pathologic categorization 2. Describe high risk populations for development of anal squamous cell cancer 3. Discuss the different options and recommendations for surveillance and treatment of anal dysplasia Video Link: https://www.youtube.com/watch?v=YdOjV1Gcqvk **Introducing Behind the Knife's Trauma Surgery Video Atlas - https://app.behindtheknife.org/premium/trauma-surgery-video-atlas/show-content The Trauma Surgery Video Atlas contains 24 scenarios that include never-before-seen high-definition operative footage, rich, original illustrations, and practical, easy-to-read pearls that will help you dominate the most difficult trauma scenarios. ***Fellowship Application - https://forms.gle/5fbYJ1JXv3ijpgCq9*** Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  If you liked this episode, check out more recent episodes here: https://app.behindtheknife.org/listen

You get called to see a consult in the middle of the night. It is a middle-aged woman with a bariatric history, and she says her stomach is smaller but doesn’t know the name of the operation. She developed worsening abdominal pain after dinner and it’s been getting worse. She’s not peritonitic, but she’s clearly in discomfort. Is it cholecystitis, diverticulitis, pancreatitis, marginal ulcer, or an internal hernia? What do you do? Join Drs. Matthew Martin, Adrian Dan, and Paul Wisniowski on a discussion about initial evaluation and management of bariatric patients with internal hernias.  Show Hosts: Matthew Martin Adrian Dan Paul Wisniowski Video companion: https://app.behindtheknife.org/video/clinical-challenges-in-bariatric-surgery-internal-hernia Show Notes 1.     Initial Evaluation a.     Focused history and physical, labs, and imaging                                       i.     Presenting symptoms may vary and include: nausea, emesis, and abdominal pain ranging from vague to severe.                                        ii.     A basic lab panel can aid in developing the diagnosis and guide resuscitation.                                     iii.     CT of the abdomen and pelvis with IV and oral contrast can assist in identifying intra-abdominal pathology                                     iv.     Reviewing the previous operative report is beneficial to have a framework of the anatomy, i.e. type of bariatric surgery, and configuration of small bowel limbs (ante- vs retro-gastric and ante- vs retro-colic). 1.     According to a 2019 study, 40-60% of closed defects had reopened at time of re-exploration                                       v.     If the patient is peritonitic with abdominal pain, they should be treated similarly to any patient with an acute abdomen with emergent exploration. b.     CT Imaging                                        i.     A mesenteric swirl sign with twisting of the soft tissue and mesenteric vessels with surrounding fat attenuation has been shown to have a sensitivity of 78-100% and specificity of 80-90%. Other findings include: a Bird’s beak, dilation of roux or biliopancreatic limbs, SMV narrowing, and displacement of JJ limb to the RUQ and can be used to support the diagnosis of internal hernia                                      ii.     An experienced radiologist familiar with bariatric anatomy has been shown to have a positive predictive value to 81% and negative predictive value to 96% at radiologically diagnosing internal hernia.                                      iii.     A CT scan can provide insight for a suspected diagnosis but it cannot rule out internal hernia c.      Nasogastric/Esophageal Tube                                       i.     Use judiciously based on patient’s presenting symptoms                                      ii.     Placement should be done by the surgical team                                      iii.     This may mitigate the risk of aspiration during intubation. 2.     Operative Management a.     Entry should be dependent on the comfort of the operating surgeon.                                        i.     Veress entry into the abdomen with dilated bowels may lead to increased injuries.                                       ii.     Optiview allows for direct visualization of each layer of the abdominal wall. Focusing on twisting the trochar and limiting perpendicular pressure.                                      iii.     Hasson entry also allows for direct visualization but may be limiting in bariatric patients with thick abdominal walls b.     Exploration – a systematic approach                                       i.     Start with evaluation of the gastric pouch and run the roux limb to the jejunojejunostomy, and examine Petersen’s and mesojejunal defects.                                       ii.     Follow the biliopancreatic limb to the ligament of Treitz                                     iii.     Lastly, identify the terminal ileum at the sail of Treves and run backwards to the jejunojejunostomy                                     iv.     This will allow for examination of all possible defect and possible intussusception at the jejunostomy c.      Defect Management                                       i.     All defects should be closed, with studies demonstrating reduced rates of internal hernia when defects are closed with a running suture. There is no strong evidence to support the use of a specific suture material. 1.     The use of suture is superior to other methods of closure such as metallic clips, fibrin glue, mesh, or abrasive pads. 2.     A barbed suture can be considered. d.     In a patient with unfavorable anatomy or those unable to tolerate pneumoperitoneum surgeons should consider early conversion to open exploration  3.     Postoperative Care a.     Patients are started on ERAS protocol with limited narcotic use, same day mobilization, early oral nutrition with advancement, and no nasogastric tubes or foley catheters b.     Patients with bowel resection and those with suspected postoperative ileus may benefit from judicious advancement of diet. 4.     Pregnancy a.     Pregnant patients with history of anastomotic bariatric surgery are at increased risk of internal hernia especially in 3rd trimester due to loss of intra-abdominal space b.     Evaluation of a pregnant patient should include abdominal imaging.                                        i.     In a non-acute setting, an MRI abd/pelvis can be considered.                                       ii.     Patients with abdominal pain presenting to the Emergency Department should undergo CT imaging.                                     iii.     The risk of radiation to a fetus, especially beyond the 1st trimester, is limited. Based on the CDC guidelines, a human embryo and fetus are sensitive to ionizing radiation at doses greater than 0.1Gray. The amount of radiation from a typical CT range from 0.015 to 0.034Gray depending if it is multiphasic or not; well below the guideline level. c.      It is important to discuss with women of child bearing age the risk of internal hernia during pregnancy with anastomotic bariatric surgery 5.     Outpatient Presentation a.     Half of patients with internal hernia will present in outpatient setting often >6 months after initial operation with complaints of intermittent nausea, vomiting, and abdominal pain b.     Workup includes: CT abd/pelvis with IV and oral contrast, Upper GI series, EGD, and a RUQ ultrasound based on their symptoms c.      If diagnostic testing is equivocal, proceed with diagnostic laparoscopy to mitigate the risk of internal hernia with bowel ischemia. **Introducing Behind the Knife's Trauma Surgery Video Atlas - https://app.behindtheknife.org/premium/trauma-surgery-video-atlas/show-content The Trauma Surgery Video Atlas contains 24 scenarios that include never-before-seen high-definition operative footage, rich, original illustrations, and practical, easy-to-read pearls that will help you dominate the most difficult trauma scenarios. ***Fellowship Application - https://forms.gle/5fbYJ1JXv3ijpgCq9*** Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out more recent episodes here: https://app.behindtheknife.org/listen

We know cardiac surgery can seem a bit daunting on the surface. However, most surgeons will come across cardiac surgery patients at some point whether in the OR, ICU, ED, etc. As the FIRST cardiac surgery specialty team for Behind the Knife, we are excited to bring you episodes focused on high-yield topics to help you navigate common cardiac surgery challenges, discuss relevant literature to help you in practice, and help our listeners feel more comfortable around cardiac surgery patients.  In this episode we’ll discuss mitral valve disease. We’ll review important physiologic differences in patients with mitral valve disease, the most common surgical approaches to address mitral valve disease, and how to work up and address acute mitral regurgitation due to acute papillary muscle rupture.  Hosts:  - Jessica Millar, MD- PGY-5 General Surgery Resident, University of Michigan, @Jess_Millar15 - Aaron William, MD- Cardiothoracic Surgery Fellow, Duke University, @AMWilliamsMD - Nick Teman, MD- Assistant Professor of Thoracic and Cardiovascular Surgery, University of Virginia, @nickteman Learning objectives: - Understand the physiologic differences that occur with mitral valve stenosis and regurgitation.  - Understand the basic principles of mitral valve repair and replacement strategies.  - Understand the presentation, work-up, and acute management of acute mitral valve regurgitations due to acute papillary muscle rupture/MI.   For episode ideas/suggestions/feedback feel free to email Jessica Millar at: millarje@med.umich.edu **Introducing Behind the Knife's Trauma Surgery Video Atlas - https://app.behindtheknife.org/premium/trauma-surgery-video-atlas/show-content The Trauma Surgery Video Atlas contains 24 scenarios that include never-before-seen high-definition operative footage, rich, original illustrations, and practical, easy-to-read pearls that will help you dominate the most difficult trauma scenarios.