Behind The Knife: The Surgery Podcast

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.

Our Cardiothoracic Oral Board Audio Review includes 43 high-yield scenarios designed for Cardiothoracic Surgeons by Cardiothoracic Surgeons. Scenarios are 5 to 7 minutes long and include a variety of tactics and styles. If you are able to achieve this level of performance in your preparation you are sure to pass the oral exam with flying colors. The second part introduces high-yield commentary to each scenario. This commentary includes tips and tricks to help you dominate the most challenging scenarios in addition to practical, easy-to-understand teaching that covers the most confusing topics we face as cardiothoracic surgeons. We are confident you will find this unique, dual format approach a highly effective way to prepare for the test. Learn more about the course and see all the episode topics here: https://app.behindtheknife.org/premium/cardiothoracic-surgery-oral-board-audio-review Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Our Cardiothoracic Oral Board Audio Review includes 43 high-yield scenarios designed for Cardiothoracic Surgeons by Cardiothoracic Surgeons. Scenarios are 5 to 7 minutes long and include a variety of tactics and styles. If you are able to achieve this level of performance in your preparation you are sure to pass the oral exam with flying colors. The second part introduces high-yield commentary to each scenario. This commentary includes tips and tricks to help you dominate the most challenging scenarios in addition to practical, easy-to-understand teaching that covers the most confusing topics we face as cardiothoracic surgeons. We are confident you will find this unique, dual format approach a highly effective way to prepare for the test. Learn more about the course and see all the episode topics here: https://app.behindtheknife.org/premium/cardiothoracic-surgery-oral-board-audio-review Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

REBOA is one spicy meatball!   On this episode, Drs. Nina Clark and Patrick Georgoff discuss the landmark UK-REBOA trial with Dr. Karim Brohi.  This is the first randomized controlled trial studying REBOA and provides invaluable information about its potential indications.    Dr. Karim Brohi is a trauma and vascular surgeon at the Royal London Major Trauma Centre and director of the London Major Trauma System, which is the largest integrated urban trauma system in the world and manages over 33,000 injuries a year.  He studied at University College of London where he obtained degrees in both computer science and medicine.  Dr. Brohi went on to train in general surgery, vascular surgery, and anesthesia/critical care in the UK and trauma surgery in Cape Town and San Francisco.  He is a prolific researcher and has led multiple large clinical trials.  Link to UK-REBOA paper: https://jamanetwork.com/journals/jama/article-abstract/2810757 BIG T Trauma episode 290 covers potential indications, placement, and complications of REBOA: https://behindtheknife.org/podcast/big-t-trauma-series-ep-2-reboa/ ***TRAUMA SURGERY VIDEO ATLAS: https://app.behindtheknife.org/premium/trauma-surgery-video-atlas ***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

Surgical resection of bilateral colorectal liver metastasis (CLM) can pose a significant challenge to even the most experienced HPB surgeon. Is surgical resection justified, if so, in which patients? What’s the best surgical approach for curative intent resection of all lesions, and does ablation play a role? In this episode from the HPB team at Behind the Knife, listen in on the discussion about the surgical management of patients with bilateral colorectal liver metastasis. Hosts Anish J. Jain MD (@anishjayjain) is a T32 Research Fellow at the University of Texas MD Anderson Cancer Center within the Department of Surgical Oncology. Timothy E. Newhook MD, FACS (@timnewhook19) is an Assistant Professor within the Department of Surgical Oncology. He is also the associate program director of the HPB fellowship at the University of Texas MD Anderson Cancer Center.  Jean-Nicolas Vauthey MD, FACS (@VautheyMD) is Professor of Surgery and Chief of the HPB Section, as well as the Dallas/Fort Worth Living Legend Chair of Cancer Research in the Department of Surgical Oncology at The University of Texas MD Anderson Cancer Center Learning Objectives: ·      Develop an understanding of patient selection for surgical resection of bilateral colorectal liver metastasis (CLM). ·      Develop an understanding of the use of Two Stage Hepatectomy (TSH) versus Parenchymal Sparing Hepatectomy (PSH) in the treatment of bilateral CLM. ·      Develop an understanding of if and when to use ablative procedures for resection of bilateral CLM. ·      Develop an understanding of selection and management of patients who suffer recurrence after resection of bilateral CLM. Suggested Readings ·      Omichi K, Shindoh J, Cloyd JM, Mizuno T, Chun YS, Conrad C, Aloia TA, Tzeng CD, Vauthey JN. Liver resection is justified for patients with bilateral multiple colorectal liver metastases: A propensity-score-matched analysis. Eur J Surg Oncol. 2018 Jan;44(1):122-129. doi: 10.1016/j.ejso.2017.11.006. Epub 2017 Nov 24. PMID: 29208318; PMCID: PMC5742306. https://pubmed.ncbi.nlm.nih.gov/29208318/ ·      Kawaguchi Y, Kopetz S, Tran Cao HS, Panettieri E, De Bellis M, Nishioka Y, Hwang H, Wang X, Tzeng CD, Chun YS, Aloia TA, Hasegawa K, Guglielmi A, Giuliante F, Vauthey JN. Contour prognostic model for predicting survival after resection of colorectal liver metastases: development and multicentre validation study using largest diameter and number of metastases with RAS mutation status. Br J Surg. 2021 Aug 19;108(8):968-975. doi: 10.1093/bjs/znab086. PMID: 33829254; PMCID: PMC8378514. https://pubmed.ncbi.nlm.nih.gov/33829254/ ·      Nishioka Y, Paez-Arango N, Boettcher FO, Kawaguchi Y, Newhook TE, Chun YS, Tzeng CD, Tran Cao HS, Lee JE, Vreeland TJ, Vauthey JN. Neither Surgical Margin Status nor Somatic Mutation Predicts Local Recurrence After R0-intent Resection for Colorectal Liver Metastases. J Gastrointest Surg. 2022 Apr;26(4):791-801. doi: 10.1007/s11605-021-05173-0. Epub 2021 Nov 1. PMID: 34725784. https://pubmed.ncbi.nlm.nih.gov/34725784/ ·      Passot G, Chun YS, Kopetz SE, Zorzi D, Brudvik KW, Kim BJ, Conrad C, Aloia TA, Vauthey JN. Predictors of Safety and Efficacy of 2-Stage Hepatectomy for Bilateral Colorectal Liver Metastases. J Am Coll Surg. 2016 Jul;223(1):99-108. doi: 10.1016/j.jamcollsurg.2015.12.057. Epub 2016 Jan 18. PMID: 26968325; PMCID: PMC4925205. https://pubmed.ncbi.nlm.nih.gov/26968325/ ·      Donadon M, Cescon M, Cucchetti A, Cimino M, Costa G, Pesi B, Ercolani G, Pinna AD, Torzilli G. Parenchymal-Sparing Surgery for the Surgical Treatment of Multiple Colorectal Liver Metastases Is a Safer Approach than Major Hepatectomy Not Impairing Patients' Prognosis: A Bi-Institutional Propensity Score-Matched Analysis. Dig Surg. 2018;35(4):342-349. doi: 10.1159/000479336. Epub 2017 Oct 14. PMID: 29032372. https://pubmed.ncbi.nlm.nih.gov/29032372/ ·      Lillemoe HA, Kawaguchi Y, Passot G, Karagkounis G, Simoneau E, You YN, Mehran RJ, Chun YS, Tzeng CD, Aloia TA, Vauthey JN. Surgical Resection for Recurrence After Two-Stage Hepatectomy for Colorectal Liver Metastases Is Feasible, Is Safe, and Improves Survival. J Gastrointest Surg. 2019 Jan;23(1):84-92. doi: 10.1007/s11605-018-3890-y. Epub 2018 Aug 6. PMID: 30084064; PMCID: PMC6329635. https://pubmed.ncbi.nlm.nih.gov/30084064/ ·      Panettieri E, Kim BJ, Kawaguchi Y, Ardito F, Mele C, De Rose AM, Vellone M, Chun YS, Tzeng CD, Aloia TA, Giuliante F, Vauthey JN. Survival by Number and Sites of Resections of Recurrence after First Curative Resection of Colorectal Liver Metastases. J Gastrointest Surg. 2022 Dec;26(12):2503-2511. doi: 10.1007/s11605-022-05456-0. Epub 2022 Sep 20. PMID: 36127553. https://pubmed.ncbi.nlm.nih.gov/36127553/ ***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 Hepatobiliary Surgery episodes here: https://app.behindtheknife.org/podcast-category/hepatobiliary

2023 was an exciting year for Surgical Palliative Care research! Join Drs. Katie O’Connell, Ali Haruta, Lindsay Dickerson, and Virginia Wang from the University of Washington to discuss two seminal randomized controlled trials in the Surgical Palliative Care space. Hosts: ·    Dr. Katie O’Connell (@katmo15) is an Assistant Professor of Surgery at the University of Washington. She is a trauma surgeon, palliative care physician, Director of Surgical Palliative Care, and founder of the Advance Care Planning for Surgery clinic at Harborview Medical Center, Seattle, WA. ·    Dr. Ali Haruta is a PGY7 Hospice & Palliative Care fellow at the University of Washington, formerly a UW General Surgery resident and Parkland Trauma/Critical Care fellow.  ·    Dr. Lindsay Dickerson (@lindsdickerson1) is a PGY5 General Surgery resident and current Surgical Oncology fellow at the University of Washington. ·    Dr. Virginia Wang is a PGY2 General Surgery resident at the University of Washington. Learning Objectives: ·    Discuss the current state of the RCT literature in Palliative Care & Surgical Palliative Care ·    Understand the primary outcomes of the Shinall and Aslakson trials as related to perioperative specialty palliative care intervention ·    Identify limitations in existing surgical palliative care RCTs & further opportunities for study ·    Identify underlying differences between medical oncology and surgical oncology patient populations References: 1.  Shinall MC, Martin SF, Karlekar M, et al. Effects of Specialist Palliative Care for Patients Undergoing Major Abdominal Surgery for Cancer: A Randomized Clinical Trial. JAMA Surg. 2023;158(7):747–755. doi:10.1001/jamasurg.2023.1396 https://pubmed.ncbi.nlm.nih.gov/37163249/ 2.  Aslakson RA, Rickerson E, Fahy B, et al. Effect of Perioperative Palliative Care on Health-Related Quality of Life Among Patients Undergoing Surgery for Cancer: A Randomized Clinical Trial. JAMA Netw Open. 2023;6(5):e2314660. doi:10.1001/jamanetworkopen.2023.14660 https://pubmed.ncbi.nlm.nih.gov/37256623/ 3.  Ingersoll LT, Alexander SC, Priest J, et al. Racial/ethnic differences in prognosis communication during initial inpatient palliative care consultations among people with advanced cancer. Patient Educ Couns. 2019;102(6):1098-1103. doi:10.1016/j.pec.2019.01.002 https://pubmed.ncbi.nlm.nih.gov/30642715/ 4.  Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302(7):741-749. doi:10.1001/jama.2009.1198 https://pubmed.ncbi.nlm.nih.gov/19690306/ 5.  Corn BW, Feldman DB, Hull JG, O'Rourke MA, Bakitas MA. Dispositional hope as a potential outcome parameter among patients with advanced malignancy: An analysis of the ENABLE database. Cancer. 2022;128(2):401-409. doi:10.1002/cncr.33907 https://pubmed.ncbi.nlm.nih.gov/34613617/ 6.  El-Jawahri A, LeBlanc TW, Kavanaugh A, et al. Effectiveness of Integrated Palliative and Oncology Care for Patients With Acute Myeloid Leukemia: A Randomized Clinical Trial. JAMA Oncol. 2021;7(2):238-245. doi:10.1001/jamaoncol.2020.6343 https://pubmed.ncbi.nlm.nih.gov/33331857/ 7.  More about the metrics from both the Shinall and Aslakson studies: a.     FACT-G – https://www.facit.org/measures/fact-g b.     FACIT-Pal – https://www.facit.org/measures/facit-pal c.     PROMIS-29 – https://heartbeat-med.com/resources/promis-29/ d.     PROPr (PROMIS-Preference) score – https://www.proprscore.com/ ***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 other surgical palliative care episodes here: https://app.behindtheknife.org/podcast-category/palliative-care