Behind The Knife: The Surgery Podcast

If you operate for long enough, chances are you will come across the unique, and potentially daunting scenario of operating on a pregnant patient. If, and when, you do, would you know what to do? Join University of Washington and MIS faculty Drs. Andrew Wright, Nicole White, and Nick Cetrulo, and residents Drs. Ben Vierra and Paul Herman as they discuss non-obstetric surgery in the pregnant patient so that you will be better informed when the challenge arises. Hosts: 1. Andrew Wright, UW Medical Center—Montlake and Northwest, @andrewswright 2. Nick Cetrulo, UW Medical Center—Northwest, @Trules25 3. Nicole White, UW Medical Center—Northwest, @NicoleWhiteTho1 4. Paul Herman, UW General Surgery Resident PGY-3, @paul_herm 5. Ben Vierra, UW General Surgery Resident PGY-2 Learning Objectives 1. Describe important physiologic changes in pregnancy that are relevant for the surgeon to know. 2. Review the epidemiology of non-obstetric general surgery in the pregnant patient. 3. Discuss specific imaging considerations in the pregnant patient. 4. Become more familiar with the technical aspects of approaching a typical surgical case in a pregnant patient. References 1. Pearl, J.P., Price, R.R., Tonkin, A.E. et al. SAGES guidelines for the use of laparoscopy during pregnancy. Surg Endosc 31, 3767–3782 (2017). https://doi.org/10.1007/s00464-017-5637-3 2. Vasileiou G, Eid AI, Qian S, Pust GD, Rattan R, Namias N, Larentzakis A, Kaafarani HMA, Yeh DD; EAST Appendicitis Study Group. Appendicitis in Pregnancy: A Post-Hoc Analysis of an EAST Multicenter Study. Surg Infect (Larchmt). 2020 Apr;21(3):205-211. https://pubmed.ncbi.nlm.nih.gov/31687887/ 3. Dongarwar D, Taylor J, Ajewole V, Anene N, Omoyele O, Ogba C, Oluwatoba A, Giger D, Thuy A, Argueta E, Naik E, Salemi JL, Spooner K, Olaleye O, Salihu HM. Trends in Appendicitis Among Pregnant Women, the Risk for Cardiac Arrest, and Maternal-Fetal Mortality. World J Surg. 2020 Dec;44(12):3999-4005. https://pubmed.ncbi.nlm.nih.gov/32737556/ 4. Fong ZV, Pitt HA, Strasberg SM, Molina RL, Perez NP, Kelleher CM, Loehrer AP, Sicklick JK, Talamini MA, Lillemoe KD, Chang DC; California Cholecystectomy Group. Cholecystectomy During the Third Trimester of Pregnancy: Proceed or Delay? J Am Coll Surg. 2019 Apr;228(4):494-502.e1. https://pubmed.ncbi.nlm.nih.gov/30769111/ 5. Hong J, Yang J, Zhang X, Su J, Tumati A, Garry D, Docimo S, Bates AT, Spaniolas K, Talamini MA, Pryor AD. Considering delay of cholecystectomy in the third trimester of pregnancy. Surg Endosc. 2021 Aug;35(8):4673-4680. https://pubmed.ncbi.nlm.nih.gov/32875420/ 6. ACOG Committee Opinion No. 775: Nonobstetric Surgery During Pregnancy. Obstet Gynecol. 2019 Apr;133(4):e285-e286. https://pubmed.ncbi.nlm.nih.gov/30913200/ 7. Ashbrook M, Cheng V, Sandhu K, Matsuo K, Schellenberg M, Inaba K, Matsushima K. Management of Complicated Appendicitis During Pregnancy in the US. JAMA Netw Open. 2022 Apr 1;5(4):e227555. https://pubmed.ncbi.nlm.nih.gov/35426921/ 8. Capella CE, Godovchik J, Chandrasekar T, Al-Kouatly HB. Nonobstetrical Robotic-Assisted Laparoscopic Surgery in Pregnancy: A Systematic Literature Review. Urology. 2021 May;151:58-66. https://pubmed.ncbi.nlm.nih.gov/32445766/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other Behind the Knife minimally invasive surgery episodes: https://behindtheknife.org/podcast-category/minimally-invasive/

Join the Hernia Team from Carolinas Medical Center as they discuss applications of artificial intelligence in predicting outcomes for patients undergoing abdominal wall reconstruction. Emerging technologies are allowing us to understand hernia patients who are at risk for increased surgical complexity and postoperative complications – find out more in this Journal Review episode. Hosts: Dr. Sullivan “Sully” Ayuso, Chief Resident, Carolinas Medical Center, @SAyusoMD   Dr. Todd Heniford, Chief of GI & MIS, Carolinas Medical Center, @THeniford   Dr. Vedra Augenstein, Professor of Surgery, Carolinas Medical Center, @VedraAugenstein  Dr. Monica Polcz, Attending Surgeon, Baptist Health (FL)  Learning Objectives: Provide and introduction to artificial intelligence Develop an understanding of the applications of artificial intelligence in surgical outcome prediction for patients undergoing hernia repair Learn how risk stratification of hernia patients can affect their care References: Elhage et al, Development and Validation of Image-Based Deep Learning Models to Predict Surgical Complexity and Complications in Abdominal Wall Reconstruction, JAMA Surgery, 2021 https://pubmed.ncbi.nlm.nih.gov/34232255/ Ayuso et al, Predicting Rare Outcomes in Abdominal Wall Reconstruction Using Image-Based Deep Learning Models, Surgery, 2023  https://pubmed.ncbi.nlm.nih.gov/36229252/  Hassan et al, Novel Machine Learning Approach for Prediction of Hernia Recurrence, Surgical Complication, and 30-Day Readmission after Abdominal Wall Reconstruction, JACS, 2022 https://pubmed.ncbi.nlm.nih.gov/35426406/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out more Behind the Knife hernia episodes: https://behindtheknife.org/podcast-category/hernia/

We’re all told to find mentors in medical training, but how does this actually work when you’re a new medical student interested in surgery? And how do you leverage those relationships into getting research experience and lines on your CV?  Hosts:  Nina Clark, MD Jessica Millar, MD Jon Williams, MD Guests:  Michael Englesbe, MD, University of Michigan Erika Bisgaard, MD, University of Washington Some tips from the episode: Get involved Even if you’re not destined for an academic career, getting involved in research early on can help you to participate with the scientific literature, understand data, and incorporate new research into your practice.   Realistically, research is an important component of your ERAS application and your CV. It’s also a great opportunity to learn new skills and develop strong relationships with mentors. Remember why you’re in medical school You came to medical school to become a doctor first – don’t forget that or let research take away from it. Your mentors have been through it and understand that things get busy. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  If you liked this episode, check out our Medical Student Intern Survival Guide Series: https://behindtheknife.org/podcast-series/medical-student-and-intern-survival-guide/ 

Experts discuss the importance and strategies of mentorship for medical students in the field of surgery. They highlight the need for different mentors who can provide support, facilitate opportunities, and hold students accountable. Effective communication, follow-through, and professionalism are emphasized. The chapter also addresses the challenges and evolving nature of mentorship relationships.

Challenges continue to plague the residency application process, with programs receiving increased application volume that makes holistic review difficult, and medical student applicants burdened with application costs and uncertainty about what programs best align with their values. As a specialty, Ob/Gyn is facing these problems head on, and have united within their field to create a new independent residency application system, ResidencyCAS. While substantial changes to an already stressful process can be intimidating, the new platform offers many advantages that hope to improve the residency application experience for applicants, programs, and the Ob/Gyn community as a whole. We’re joined by Dr. Maya Hammoud and Dr. AnnaMarie Connolly, two of the leaders in this effort, to break down the creation of ResidencyCAS, plans for its implementation starting in the 2024-2025 application cycle, and the reaction of the Ob/Gyn and medical education communities to this change. Learning Objectives 1.     Listeners will describe current challenges to applicants and programs in the residency application process. 2.     Listeners will identify the coming changes to the Ob/Gyn residency application process, with awareness of the planned design and use of the ResidencyCAS system. 3.     Listeners will describe the value of potential changes to the residency application process. 4.     Listeners will explain the barriers and efforts required to coordinate large-scale changes within medical education like the creation and implementation of ResidencyCAS. 5.     Listeners will consider how changes to the residency application process could affect and improve their own field, program, or application. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our other Surgical Education Episodes: https://behindtheknife.org/podcast-category/surgical-education/

Direct Peritoneal Resuscitation!  We’re not just dumping fluids into the open abdomen.  What is DPR?  Why do it?  Who should get it?  Does it work? Come try and stay awake for some basic science talk before then learning all about why you should consider adopting DPR into your Trauma/EGS practice? Join Drs. Cobler-Lichter, Kwon, Meizoso, Urréchaga, and Rattan as they guide you through all this and more!  Hosts: Michael Cobler-Lichter, MD, PGY2: University of Miami/Jackson Memorial Hospital/Ryder Trauma Center @mdcobler (twitter) Eva Urrechaga, MD, PGY6/R4: University of Miami/Jackson Memorial Hospital/Ryder Trauma Center @urrechisme (twitter) Eugenia Kwon, MD, Trauma/Surgical Critical Care Fellow: University of Miami/Jackson Memorial Hospital/Ryder Trauma Center Jonathan Meizoso, MD, MSPH Assistant Professor of Surgery, 3 years in practice University of Miami/Jackson Memorial Hospital/Ryder Trauma Center @jpmeizoso (twitter) Rishi Rattan, MD, Attending Surgeon in Trauma/Critical Care, 7 years in practice Legacy Emanuel Medical Center @DrRishiRattan (twitter) Learning Objectives: - State the proposed benefits of DPR - Identify who can benefit from DPR - Demonstrate the proper way to set up a DPR circuit - Discuss the proposed basic science mechanism for DPR’s efficacy Quick Hits: 1.      Consider DPR in all your open abdomens in EGS/Trauma.  You never know when you’re going to be able to close some of these patients. 2.     The principal of DPR is to allow the fluid to dwell in the abdomen as long as possible.  Keep the catheter deep and don’t put holes in your dressing. 3.     DPR is ideal for patients with packing, who are in discontinuity, and for fresh anastomoses.  These will only benefit from DPR, not be harmed by it.  4.     Make sure these patients are receiving hourly I/Os.  Nursing by-in is huge for this procedure. 5.     DPR is associated with higher rates of fascial closure, reduces inflammation, and improves blood flow to the abdomen. References Ribeiro-Junior MAF, Cássia Tiemi Kawase Costa, de Souza Augusto S, et al. The role of direct peritoneal resuscitation in the treatment of hemorrhagic shock after trauma and in emergency acute care surgery: a systematic review. Eur J Trauma Emerg Surg. Published online November 13, 2021. doi:10.1007/s00068-021-01821-x Smith JW, Garrison RN, Matheson PJ, Franklin GA, Harbrecht BG, Richardson JD. Direct Peritoneal Resuscitation Accelerates Primary Abdominal Wall Closure after Damage Control Surgery. J Am Coll Surg. 2010;210(5):658-667. doi:10.1016/j.jamcollsurg.2010.01.014 Smith JW, Neal Garrison R, Matheson PJ, et al. Adjunctive treatment of abdominal catastrophes and sepsis with direct peritoneal resuscitation: indications for use in acute care surgery. J Trauma Acute Care Surg. 2014;77(3):393-398; discussion 398-399. doi:10.1097/TA.0000000000000393 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 episode here: https://behindtheknife.org/listen/

Join Professor Michael Solomon, Dr Kilian Brown and Dr Jacob Waller from Royal Prince Alfred Hospital in Sydney, Australia, for this special four part series on pelvic exenteration surgery for locally advanced and recurrent rectal cancer. Learn about these ultra-radical procedures which go beyond the traditional TME planes that we learn during surgical training, and into all compartments of the pelvis. Episode 2 outlines the radical technical approaches to anteriorly invasive tumours, including en bloc cystectomy, perineal urethrectomy, inter-labial vaginectomy and radical pubic bone resections. Each episode in this series features a different international guest surgeon. In episode 2, the RPA team are joined by Dr Paul Sutton from The Christie Hospital, Manchester, UK. Technical videos: Solomon MJ, Däster S, Loizides S, Sutton P, Brown KGM, Austin KKS, Lee PJ. Access to the anterior pelvic compartment in pelvic exenteration in women-the interlabial approach: video vignette. Br J Surg. 2021 Aug 19;108(8):e268-e269. doi: 10.1093/bjs/znab127.  Solomon MJ, Alahmadi R, Lee PJ, Austin KKS. En bloc partial pubic bone excision with complete soft tissue pelvic exenteration. Br J Surg. 2022 Jun 14;109(7):640-641. doi: 10.1093/bjs/znac122. PMID: 35485605. References: Solomon MJ, Austin KK, Masya L, Lee P. Pubic Bone Excision and Perineal Urethrectomy for Radical Anterior Compartment Excision During Pelvic Exenteration. Dis Colon Rectum. 2015 Nov;58(11):1114-9. doi: 10.1097/DCR.0000000000000479.  Check our more high-yield colorectal surgery content from Behind the Knife.

Join Professor Michael Solomon, Dr Kilian Brown and Dr Jacob Waller from Royal Prince Alfred Hospital in Sydney, Australia, for this special four part series on pelvic exenteration surgery for locally advanced and recurrent rectal cancer. Learn about these ultra-radical procedures which go beyond the traditional TME planes, that we learn during surgical training, and into all compartments of the pelvis. Episode 1 provides listeners with an overview of the principles of exenteration surgery and preoperative patient assessment and selection. Each episode in this series features a different international guest surgeon. In episode 2, the RPA team are joined by Dr Elaine Burns from St Mark's Hospital, London, UK. References and further reading: -Burns EM, Quyn A; Lexicon Collaboration of UKPEN and the ACPGBI Advanced Cancer subcommittee. The 'Pelvic exenteration lexicon': Creating a common language for complex pelvic cancer surgery. Colorectal Dis. 2023 May;25(5):888-896. doi: 10.1111/codi.16476.  -Brown KGM, Solomon MJ. Decision making, treatment planning and technical considerations in patients undergoing surgery for locally recurrent rectal cancer. Seminars in Colon and Rectal Surgery. 2020;31(3):100764 -van Kessel CS, Solomon MJ. Understanding the Philosophy, Anatomy, and Surgery of the Extra-TME Plane of Locally Advanced and Locally Recurrent Rectal Cancer; Single Institution Experience with International Benchmarking. Cancers. 2022 Oct 15;14(20):5058. doi: 10.3390/cancers14205058 -PelvEx Collaborative. Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative. Cancers (Basel). 2022 Feb 24;14(5):1161. doi: 10.3390/cancers14051161  Check out more high-yield colorectal surgery content from Behind the Knife: https://behindtheknife.org/podcast-category/colorectal/

This week, we discuss the experiences of residents and medical students in surgery who identify as LGBTQIA+. We discuss the question of disclosure during interviews, how to identify programs that are welcoming to diverse identities, and how AOSA has grown the community of trainees and faculty mentors and hopes to continue to support them in the future. Hosts: Jason Bingham, MD Nina Clark, MD Guests: Andrew Schlussel, DO, Colorectal and General Surgeon, Charlie Norwood VA Medical Center Christina Georgeades, MD, R4 General Surgery at Medical College of Wisconsin cgeorgeades@mcw.edu, Twitter/X: @CGeorgeades Cameron Smith, MS3 at Kansas City University Cameron.smith@kansascity.edu, Instagram: @cameron_smith_1996, Twitter/X: @cafe_aficionad0 Jillian Wothe, MD, R1 General Surgery at Brigham & Women’s Hospital jillian.wothe@gmail.com, Twitter/X: @JillianWothe Learn more and get involved with AOSA: https://www.outsurgeons.org Twitter/X: @OutSurgeons Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out episode one in this series: https://behindtheknife.org/podcast/association-of-out-surgeons-allies-aosa-episode-1/

Has the pendulum swung too far?  Is it time to put the drill down??  Or, drill, baby, drill!  While the number of rib plating cases has exploded the data supporting the practice is less-than-stellar.  On this episode of the BIG T Trauma series Drs. Patrick Georgoff, Teddy Puzio, and Jason Brill bring you up to speed on rib plating. If you haven’t already, we recommend you listen to Behind the Knife episode 298, published in May 2020. (https://behindtheknife.org/podcast/big-t-trauma-series-ep-10-rib-fractures/)  This episode covers comprehensive management of rib fractures, including multimodal pain control, regional blocks, pulmonary toilet, BiPAP, etc.   REFERENCES: GUIDELINES EAST PMG Rib Plating (2017): https://www.east.org/education-resources/practice-management-guidelines/details/rib-fractures-open-reduction-and-internal-fixation-of-update-in-process EAST PMG Rib Fracture Non-Surgical Management (2022): https://www.east.org/education-resources/practice-management-guidelines/details/nonsurgical-management-and-analgesia-strategies-for-older-adults-with-multiple-rib-fractures-a-systematic-review-metaanalysis Chest Wall Injury Society Guidelines (2020): https://cwisociety.org/wp-content/uploads/2020/05/CWIS-SSRF-Guideline-01102020.pdf FLAIL/UNSTABLE CHEST Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries: A Randomized Clinical Trial, JAMA 2022: https://jamanetwork.com/journals/jamasurgery/fullarticle/2796556 Prospective randomized controlled trial of operative rib fixation in traumatic flail chest, JACS 2013: https://pubmed.ncbi.nlm.nih.gov/23415550/ Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status, Interact Cardiovasc Thoracic Surg 2005: https://pubmed.ncbi.nlm.nih.gov/17670487/ Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients, J Trauma 2002: https://pubmed.ncbi.nlm.nih.gov/11956391/ Surgical Rib Fixation of Multiple Rib Fractures and Flail Chest: A Systematic Review and Meta-analysis, J Surg Research 2022: https://pubmed.ncbi.nlm.nih.gov/35390577/ Surgical versus nonsurgical interventions for flail chest, Cochrane Review 2015: https://pubmed.ncbi.nlm.nih.gov/26222250/ NON-FLAIL CHEST Randomized Controlled Trial of Surgical Rib Fixation to Nonoperative Management in Severe Chest Wall Injury, Ann Surgery 2023: https://pubmed.ncbi.nlm.nih.gov/37317861/ Rib fixation in non-ventilator-dependent chest wall injuries: A prospective randomized trial, J Trauma 2022: https://pubmed.ncbi.nlm.nih.gov/35081599/ A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (NONFLAIL), J Trauma 2020: https://pubmed.ncbi.nlm.nih.gov/31804414/ Operative versus nonoperative treatment of multiple simple rib fractures: A systematic review and meta-analysis, Injury 2020: https://pubmed.ncbi.nlm.nih.gov/32650981/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out the rest of the BIG T Trauma episodes here: https://behindtheknife.org/podcast-series/big-t-trauma/