Episode 4
Training the Next Generation of Surgeons with Dr. David Farley
Episode Transcript
Dr. Randy Lehman: [00:00:07] Welcome to the Rural American Surgeon. I'm your host, Dr. Randy Lehman. On this show, you'll receive powerful insights and resources for rural surgeons. I'm a general surgeon in northwest Indiana, and this show is tailored around the nuts and bolts of rural general surgery practice. But you'll find topics ranging from practical surgical tips to a host of others, including rural lifestyle, finance, training, practice models, and more.
We'll have a segment called Classic Rural Surgery Stories where you'll get a feel for how practice in the country differs from the city. Whether you're a surgeon, other specialist, primary care, or simply someone interested in healthcare for rural America, I'm glad you're here. Now let's get into the show.
Welcome back to the Rural American Surgeon Podcast. And I have today the man, the legend, David Farley, old program director from Mayo Clinic, instrumental in my training and in the training of several hundred other Mayo Clinic residents. Thank you so much, Dr. Farley, for joining us.
Dr. David Farley: [00:01:04] Pleasure. Happy to be here.
Dr. Randy Lehman: [00:01:07] And let's start with an introduction of you, Dr. Farley. So tell us a little bit how you grew up and maybe your connections to rural and then what you did throughout your career and what you're doing now and in the future.
Dr. David Farley: [00:01:17] Okay, so I'm a rural Wisconsin boy. I was born in Portage, Wisconsin, lived in Pardeeville, Wisconsin, about 500 people, lived in Sparta, Wisconsin, about 5,000 people. Screwed around and got my wrist cut and saw the doctor there, a family doc sew it up for me at age 5. That was kind of cool.
Lived in Racine, then lived in River Falls. And I had a very nice upbringing. Had an athletic father and a great mom and an older brother and a younger brother. Very athletic family. I played golf at Wisconsin, went to medical school at Wisconsin, and then I joined the Mayo Clinic as a trainee. I was there for six years, five in general surgery, one in research.
Then I spent six months in Germany as a special Mayo scholar, basically to improve my skills on pancreatic surgery, but more importantly for me, finding a new passion about surgical education, how things were going in Germany, and I didn't like what I saw. And I was thinking we could do better at Mayo. And then I spent the next 31 years in Rochester teaching and training guys like you and gals that are just as bright or brighter.
Dr. Randy Lehman: [00:02:26] And then retired around the same time I left or just before 2019, the.
Dr. David Farley: [00:02:31] Fall of 2019, before COVID. The last straw for me was Epic, the having to chart in and whatnot. I've on average for 31 years put in about 75 to 80 hours a week, and Epic cost me another 45 minutes every day from what I was doing. And my wife was long since frustrated, and I said uncle at that point. And so I got out. It was good timing.
Dr. Randy Lehman: [00:03:02] Sure. And what have you done with your time since then?
Dr. David Farley: [00:03:06] Well, I've got a variety of things. I got some grandkids. I'm spending more time with my wife and kids. I love to play pickleball. I'm a gardener. My wife's a big outdoors person. Four-wheeler, snowmobiling, hunting. So I operate twice a year. It's each fall she usually bags two deer. So I do a little dissection there. I still do some surgical simulation teaching. I work for the American College on a couple projects that I really hope at some point rural surgeons will get a chance to see these things, interact with them and find them useful.
Dr. Randy Lehman: [00:03:41] So a little laparoscopic deer dissection in the fall. And other than that, kind of keeping it low key.
Dr. David Farley: [00:03:46] Yeah, it's good. It's open dissection and it's resection mostly. It's not much dissection.
Dr. Randy Lehman: [00:03:53] Very good. So I like to ask all my guests, and I think the classic guests are probably going to be practicing rural surgeons. But it's great to get sort of a person that has a different perspective and especially event for training like yourself on here. But one of the questions that I'd like to ask is why is rural surgery special to you?
Dr. David Farley: [00:04:13] Well, it's a couple different things. Number one, my uncle was a general surgeon. He wasn't in a rural practice, but he was in a very private practice in Minneapolis-St. Paul. And he was a general surgeon in the 50s, 60s, 70s, and I got to operate with him and help him out in the 80s. And he was the kind of guy that was doing carotid surgery. He was doing tracheostomy, doing a lot of endocrine stuff. He was pinning hips. He was, you know, anything colon, breast, hernia, gallbladder, you name it.
In my mind, he was a true general surgeon. And in my mind, the only real general surgeons are rural surgeons and those pediatric surgeons maybe that have a very special practice. So, you know, Mayo Clinic is not a rural practice. I never practiced rural surgery, but I had some rotations as a trainee in La Crosse and in Hennepin and Shawano, Wisconsin. And I know what it's like. I loved it. I love the idea of taking care of a community, growing with a community and being there for your community.
So I just took the attitude, as a Mayo Clinic program director, I got a chance to touch the lives of about 600 surgeons. Most of those are general surgeons, and I'd say about one in six have a rural type practice. And I couldn't be prouder of what you and others are doing every day. I live vicariously through you people. I figure if all those 600 surgeons each do one operation a day or even a week, I've had a very productive week. As long as it's done safely, right?
Dr. Randy Lehman: [00:05:51] Yeah. Well, trust me, your voice is ringing through our heads, all of our cases, as we continue through the iliac. You know, I can hear it every day. Don't worry.
Dr. David Farley: [00:06:05] Hopefully it's not pathologic. Hopefully it's helpful.
Dr. Randy Lehman: [00:06:08] No, it's good. If it was pathologic, you wouldn't be here. So, yeah, we really appreciate it. Let's roll into the "how I do it" section of the show. So we've agreed you were sort of a leader in bringing the TEP inguinal hernia to Mayo Clinic. Talked a lot of trainees through it. I know that you've broken it down in your head step by step. And so for the "how I do it" section, there's going to be several people that will be listening to this. There may be students that have never seen it. There may be residents or early trainees. And so with those things in mind, don't be afraid to make it too simple. And I may dumb it down even further and ask you about things, but talk to me about your approach to TEP and the first initial steps.
Dr. David Farley: [00:06:49] Okay, so first off, should you use a TEP? And the answer is sometimes yes, sometimes no. And I know it's fallen out of favor, robots, open surgery. But I like TEP, especially in somebody that likely has a bilateral hernia or somebody that has a recurrent hernia that previously had an open repair. I like to get into that virgin space.
So they need to be fit enough to undergo general anesthesia. If that's not the case, then I don't want to do a TEP. So let's say we got somebody with a bilateral hernia wants to get back active right away like most patients do. And so they need to go under general anesthesia. And in the operating room, they're under general anesthesia. Curvilinear incision underneath the belly button. A couple of S-shaped retractors dissect down to the rectus fascia. Not in the middle, off the midline. Dealer's choice. Whichever one if the person was symptomatic with a right-sided hernia, I would probably pick the left side just because the camera might be a smidge further away from the right side.
And the further back you can get, the better the picture. So you make a little longitudinal fasciotomy in the rectus fascia, the anterior rectus fascia. You should see muscle. So I usually made a 1-cm incision. Use those little S-shapes. Use the big curve, not the little curve, the big ones, and spread. See the muscle and then get the muscle from medial to lateral, push it out of the way.
And then you should see the posterior rectus fascia. And once you see that, you slide your S-shape underneath the rectus muscle, hook it underneath the fascia, and you have your balloon dissector lubricated [original: "gooed up with some goo"]. And then you slide it into that hole and it's a corkscrew. You know, wiggle, jiggle. I'm kind of a Parkinson's kind of a guy. I like to find an easy path, keep the tip up as the tip goes down.
I've had hundreds of students and interns that can do this, so it's not dangerous. Wiggle, wiggle, wiggle. Keep it anterior so the tip bumps into the pubic bone. So if it's me with my right hand, I've got the balloon dissector. I got my left hand feeling where the pubic bone is. And this thing is going to slide behind that rectus muscle. It's going to be anterior to the posterior rectus fascia, and it's going to get into that preperitoneal space.
It just magically slides in there and you bump into the pubic bone. And I usually bump, feel it, you know, layman, show me, bump it into it, and it can feel that. And from there, depending on the product that you're using, you use the balloon. Some were 10 puffs, some were 30. You get a sense. I always took the camera and looked inside.
So now you're inside with the camera looking in the preperitoneal space. And you got to think to yourself, okay, let's get north up. Let's get the pubis straight up and down. Let's get our orientation. Because if you're not oriented, it's a really dangerous and scary operation. So you bump into the pubis, you back up, the balloon's blowing up, the camera slides in and you can see the pubic bone.
And as it inflates, you will tend to see a hint that there's the right pubic bone and there's the left pubic bone. And as it expands, you'll tend to see the inferior deep Epigastric artery and vein that might get pushed to the side. It sort of depends. If the person has a direct hernia, you'll see the pseudosac, the hernia sac of that direct hernia, into the balloon.
And that would be a first question for me to ask my trainees: Do you see the pubis? Do you see the Epigastric? If it's medial to the Epigastric and the pseudosac is there, we got a direct hernia. Doesn't mean there's not an indirect or a lateral defect, but it means we've got that and we need to fix it for sure.
So once we get it dissected, that balloon about not as big as a volleyball, maybe half as big as a volleyball, but bigger than a softball. Got to be careful, too. As you inflate it, you may cause bradycardia in the patient. You know, let your anesthesiologist know as you put the balloon in to say you may need a little help here with the bradycardia. And if that's the case, I always deflated the balloon and let it collapse. Let the anesthesia figure that out, put a little more fluid on board, and away we go.
So let's say we blow up the balloon. Everything's good. I got my S-shape behind the balloon. I deflate the balloon, I pull the balloon out. I've got now the pathway into this preperitoneal space. And now I'm going to put my camera in there, hook it up to CO2 and insufflate the pressure. We can argue what the right pressure is, but just remember, the greater the pressure, the more you're going to compress stuff. And you may dissect further than you want. And every now and then somebody gets an air embolism, a little break in a blood vessel, and that can happen. That never happened to me, I don't think. I certainly didn't see it in my visualization of the patients, but I operated on probably 2,500 people and, you know, 5,000 bilateral repairs.
And so trying to keep the pressure as low as you can. You put the camera in, you open up that space, and now you need access. You've got an assistant. You're really relying on that assistant. So Dr. Lehman can't, in my opinion, run the camera and both ports doing a TEP hernia. So you need a camera person that you can count on, whether that's a scrub nurse, a surgical assistant, a medical student, a resident, doesn't matter. But they need to be able to orient this thing.
So up is up and down is down. And then to follow carefully and keep my instruments in view, I make two transverse incisions that are 5-millimeters in size. The first one is just cephalad to the pubic bone. It is in the midline. I would like to hit the median raphae. I would like to split between the two rectus muscles.
And then I will take my trocar. Once I stretch that skin a little bit, the trocar goes in. And depending on what kind of trocar it is... When I first started this, I had these razor-sharp things that I just loved. But they're dangerous as heck because you impale them, they go into the bladder. So it was always a wiggle. And so barely show it to me. Slow down, Lehman, slow down. You know, you want to make sure this thing just barely pops in.
I've got a few videos that show it this sudden thing. And, you know, it's why I got gray hair now. So you get the first one in. The second one needs to be as far away as possible, but it can't be banging into the camera. So it's about halfway between the two of them. It's nice if it's at least 3-cm from the one by the pubic bone.
Same thing. I make a transverse incision, spread the skin, wiggle, wiggle down. The camera person's got to back up because that trocar is coming in. And so now I've got two trocars in place. I fix them in place and I'm ready to go. When I first started with the TEP hernia, I had typical graspers, you know, just atraumatic or some sort of grasping thing.
And now I have these, you know, what I was calling pinchers or just tweezers. And they were so much better than the looped things. And I actually got my thumbs were, you know, arthritic with that. So I got something that I could just pinch. So I put the pinching things in, and then from there it's, in my mind, relatively straightforward.
I never use the cautery. I try and avoid that at all possible. And the first thing I do is I want the two graspers to come down and touch together. So if it's you as the surgeon or somebody else you're watching, show me that you know that you're in a little space, you know, less than a softball. It's a tiny space. Bang that together.
And then when you move, move around together with your two fingers so that we're not all over the place that the tips are gone. So once you have that, I ask, touch the pubic bone so you know where that is. If you slide down the pubic bone laterally, iliac vessels are there. I don't want to see those. I don't want to touch them, but that's where they are.
Then I want to slide up, and I want to find deep inferior Epigastric artery and vein. Usually two veins and one artery. And I want to keep it up every now and then. Maybe one in 2,000, the Epigastrics would drop down, but keep them up. And from there, you keep that up, and you dissect one hand up, one hand down, one hand up, one hand down, and you keep stretching that space, and you get to the point that you're actually, hey, that's the internal ring.
I'm getting a sense that the spermatic cord's coming around, hey, I'm sliding out. This is going to be outside, toward the transversalis. We're going to see that. And so then it becomes a matter if it's a male or a female. TEP hernia is a great repair for a femoral hernia in a woman. And I've had multiple ladies come to me after one, two, or three attempts at fixing a femoral hernia, and nobody went in from the backside, whether that's a TEP robotically or laparoscopically or a TEP.
But I think if you have a female that has the potential of a femoral hernia, think long and hard about TEP or TAPP. So at that point, I'm looking to find, is it the round ligament of a female? Is it a male? And I'm looking for an indirect sac, that sac that goes around that corner up into the internal ring.
And it's hard to describe, but at some point, you're looking for this whitish sac that invariably, in my mind, I'm grabbing with my left hand. I'm putting traction on it, I'm pulling it kind of toward the pubis. And then with my other tweezers, I open up the grasper and the bottom part, like my thumb. I'm going to find that white sac and sort of push it, being careful that the top of the grasper doesn't hurt the Epigastric or hurt anything.
I'm not past pointing, but I'm kind of scraping like a shovel on a sidewalk, that sac. And the sac is pretty firm. And at that point, it becomes a game. All right, I don't want to put a hole in the sac, but I'm trying to create this deflated balloon and then get it back at some point that it's going to fall back and be out of the internal ring.
I look at my direct spot. Is there a direct hernia there? Doesn't matter if there is or not. I just need to know that because I am going to put mesh over both those spots, and then I will look at the iliac vessels or where I think a femoral hernia should be. And there have been many, many patients that I did the triple. The triple on one side and even had one lady with seven hernias, three on one side and four on the other with an obturator hernia.
And depending on how you cut the mesh, you can cover them all. And you know, what a great advantage, looking from the inside, whether it's a TEP or a TAPP, you can probably see more. You got a wider view. With the TAPP, you can see the appendix and the bowel and whatnot. But with the TAPP, what I didn't like about it is now you've got some transverse incisions and you've got a more likelihood of developing a hernia.
Whereas my incisions, if I'm doing a TEP, I got two that are 5-millimeters. I never had a hernia through one of those. And that infraumbilical incision, as long as you make the incision on the anterior rectus and keep the posterior intact, I never had a hernia there. So it was 5,000 times doing that, not having a hernia. And I know there's people that have hernias with laparoscopic cholecystectomy with TAPPs and whatnot.
So that's an advantage, a disadvantage. It's a smaller space. You got to be careful. But it's one of those things like anything else. When we get repetition, you get good at it. And you can do a bilateral TEP in 22 minutes. I did one case by myself in my 31 years at Mayo. It was me and a first assistant, Brad, and we did a bilateral TEP. We didn't have any trainees. They couldn't make it, they were busy, they were tied up.
And so, all right, from skin to skin, 22 minutes. That's what we're shooting for. And I always, selfishly or badly, I always said, I'm willing to do this in an hour and I will let my trainees struggle some. As long as I'm coaching and they're making progress. And if they could get the one side done in 45 minutes, then I'd, you know, switch on the left side and say, let's not spend two hours and fix this. Let's do this in 60 minutes if we can.
So if you've got it all dissected back, you know, the TEP or the TAPP, you can see the genitofemoral branch, the nerve, if the person's skinny; if they're fat, you probably won't. The lateral femoral cutaneous, you'll see it if they're skinny, if you know where to look. But if they're fatter, then you probably won't. I try not to mess with any of that stuff.
And the piece of mesh ideally is about 4 inches by 6 inches. I usually, instead of a rectangle, I trimmed off part of it that I was going to put on the pubic bone. I didn't want to put the mesh down where the bladder would have more access to it. And I had actually one urologist at Mayo, God bless him and rest in peace, that was tough on me.
He was really upset that I did a TEP because he wanted no part of that with doing any bladder operations that might get stuck down there. So because of him, I always trimmed off the corner to try to minimize putting the bladder up against the mesh and then putting the mesh in place.
There's a variety of ways to do that with a tacker, a permanent absorbable with... What do you call that? Velcro-like stuff that sticks in there. I did a study with that. I did 20 in one arm and 20 in the other. That's a terrible study. It's not big enough. But I had one recurrence with the Velcro, and I didn't have any with the other. So I stuck with my own tack.
I started out with metal clips, and by the end there was an absorbable thing. Then invariably I would say a couple tacks just on the anterior edge of the pubic bone, meaning Cooper's ligament, a little fascial anteriorly on one side of the deep inferior Epigastric. And I put a couple up top out laterally, but I wouldn't put any down below. I'm not looking to hurt any sort of nerves, and any tack has to be above the inguinal ligaments, so I should be able to feel it.
If you're out lateral and you can feel it, you're not going to hurt any nerves there. If you can't feel it and you're feeling for this and you're pushing, you might likely hit the lateral femoral cutaneous nerve. And I did operate on four or five people that came to Mayo with injuries from surgeons that, you know, tried their best but, you know, nailed that thing. So I'm sorry, that's a soliloquy. That's a lot of babbling. What can I explain better?
Dr. Randy Lehman: [00:21:30] That's perfect. I didn't have to lead you through anything, but I did have a couple follow-up questions. So first off, when you're placing the mesh, you're describing cutting, I assume a flat piece of mesh, right? Not a pre-curved or pre-shaped mesh. Is anybody doing TEP with a pre-shaped mesh?
Dr. David Farley: [00:21:47] Yeah, I never used it. That stuff existed and had some flaps and whatnot. But I was very happy with a flat piece of mesh. It's much easier to manipulate. It was quicker and I thought my patients, you know, from the inside, I really like that advantage of having a hole and the mesh being on the inside so it's pushed right up. Blocking that hole, as opposed to Lichtenstein, is a wonderful repair and it's great. But I was always nervous that I'd rather have it on the inside.
Dr. Randy Lehman: [00:22:15] Any special tips for when you put the mesh in to label it to make it easy to unroll and orient it?
Dr. David Farley: [00:22:21] Well, good question. Yes. It's been five years since I've done one, so I forgot to say that. So I've got my mesh and I've cut off this triangle because that's going to be on Cooper's ligament. So I'm going to eventually try to get it in there.
So what I'd like to do is fold the top down, fold the bottom up, make it one-third the thickness, grab the medial aspect where that triangle is off, grab the medial aspect, slide that mesh in. So it's going to open up with the top. Let's say I'm fixing a right-sided hernia. The top's going to open to the right and the bottom is going to open to the left and the triangle is going to be on the left side.
At that point I take the two tweezers and tap the mesh down so it sits on the bladder. And at that point it's usually famous last words, two moves. The left hand grabs the top of the mesh, the middle of that mesh, if you will, not down by the triangle, but on the top anterior side. I'm going to grab that up, sort of put it where I think it belongs maybe just lateral to the Epigastric. And my right hand is going to come in and sort of swat this thing away. And it's kind of a letter opener. Sometimes it would roll and you just slide it along and the top falls in place. But you know, sometimes it was screwy. But if you grab the mesh with a big bite and not crinkle it, but get it at the top. And my tweezers, I don't know are a 1.5-centimeter bite.
You know, you can move it around like a stiff flag a little bit and that's, that works pretty slick. And then you can get it in the spot, tap it in place. That way the little bit of blood or a little fluid, it would stick and you could see it and you could be confident that you could tack it easily in place.
Dr. Randy Lehman: [00:24:04] Very good. Well, that's excellent. So the only other follow-up question I have is if someone would like to learn more about TEP inguinal hernia repair, is there a place, a resource website, a company that you would recommend that they call to get more information, maybe even training on it if they'd like to try?
Dr. David Farley: [00:24:22] I don't have anybody right now that I would peddle. I would... If somebody wants to, you could send me a note, an email: david55farley@mail.com. I've got in the past when it was Twitter, I probably put 100 tweets on. Some of them are on and I do have some, you know, thumb drives and I've given, you know, a couple dozen, if not 100 talks on it so that I could send out. I don't have any patents on any stuff and if it helps somebody do a safe operation, it would be, I would be happy to do that.
Having said that, I would be reticent to just tell everybody, "Yeah, go right ahead." Because I think having a mentor and having a colleague there and coaching you for the first one or two or three or four is probably a good thing because it's nerve-wracking, especially if the camera person changes that thing. And up is not up, you can get into real problems. But I'm sorry, what about ordering the equipment?
Dr. Randy Lehman: [00:25:26] So you know, you'd have to call or somebody at your hospital would have to call the company to get the... you know, let me give you an example of where I'm at. So I'm in three critical access hospitals. We're talking two operating rooms, one endoscopy suite. I've got five total techs in my OR, five total OR nurses in my hospital, four techs. And one of those techs is in charge of ordering all this stuff. So I want a J2 or anything, like I just tell them and I've got to pick it out of the catalog.
Dr. David Farley: [00:25:55] Yeah.
Dr. Randy Lehman: [00:25:55] So is it Bard or Applied or who's the best company to call? I mean, I'm not... I don't have any affiliations, nor do I...
Dr. David Farley: [00:26:03] And I'm five years out. And one of the great things about the Mayo Clinic was I would ask and there's somebody in charge of ordering all that stuff and said, "Okay, do you want a 30° scope or a 45° scope? We got a contract with Bard or Storz or whatever and this is what we have." And I said, "Well, can they come and demo it for me?" Yeah, I'd really like that. You know, the American College every year has somebody has people demoing their stuff and other conferences do as well. But I'm sorry, Randy, I can't... I can't give you the name. My data is all 5 years old and it's biased.
Dr. Randy Lehman: [00:26:39] Yeah, that's a great place to recommend. If you go to the College and check out some of the booths and there's probably videos and maybe even practice equipment that you can get your hands on. If you're interested in doing TEP, it's probably worth mentioning that you know what I do and I feel comfortable doing a TEP, but I think you need to choose what you want to do.
And I have enough people that there's a thing I want to look on the inside. And so I've been doing TAPP. I don't have a robot at any of the hospitals I'm working at. I use the Bard 3D Max mesh, which does have a pre-shape, and I put it in place with the SecureStrap, which is the absorbable tacker. I use the dissection, basically the same as what you're talking about, except for dissecting it free. And then everything... When I secure it back up, I use the SecureStrap, have had pretty, pretty nice outcomes with that, patient's pretty happy. And then I just…
If I have an open or if I have a patient that comes in with a unilateral initial inguinal hernia, especially if it's a man, then I fix that with a Lichtenstein technique. If I'm worried about a hernia on the other side or if I know there's a hernia on the other side, bilateral hernia, they get a laparoscopic repair. If they've had a recurrence after an open, they get a laparoscopic repair.
The recent guidelines say that women, all women should have a laparoscopic repair because of the femoral and everything. I got a little too cavalier on that with one patient that had had multiple previous abdominal surgeries, and then I kicked myself because the way the operation ended up going is there's tons of adhesions on the inside and it was a unilateral hernia. It's just a palpable little marble and I should have just done her open.
So take all the guidelines with a grain of salt, obviously. And I'm not the end-all be-all for surgery. That's why I've got people on. And mostly I want to use this "how I do it" segment to show that there's key steps that have to be accomplished in every operation, but there's tons of ways to get that operation done and there's not a right or wrong answer. And sometimes I would feel like I'm out... And you know, you have to make a decision. That's the thing about surgery and you have to decide what you are going to do and you have one time to do it. It's a little bit of a lot of pressure, I guess, on you. And to know that there's a lot of people doing it a lot of different ways, many things, there's not a right or wrong is a little bit more settling, you know.
Dr. David Farley: [00:28:57] Yeah. I'm not going to argue with you. I think a TAPP is a great approach. Having said that, I smirk a little bit to say what if you'd have done a TEP on her, you'd have been prepared medially the whole time. You probably would have been a piece of cake. Having said that, your point is a good one. You get good at something, then that should be your go-to for the most part. And if your other choice is Lichtenstein, I'm not going to fault that one bit. Not, not a bit.
Dr. Randy Lehman: [00:29:22] Some of her lower operations, I can't remember the details, but if it wasn't a lower midline, it was at least a Pfannenstiel. So what do you think about that? Like if somebody had a radical prostatectomy or whatever?
Dr. David Farley: [00:29:37] Yeah, I tried to avoid... Yeah, I tried to avoid it. I did a couple. They were doable, but oftentimes I'd have a hole or two in the peritoneum, which I did not like at all. So mea culpa, just like you. If it was a radical prostatectomy, I said, "No, I'm not going to do that," or I would... If the person came to me said, "Well, I know you're an expert, this laparoscopic stuff." I said, "Here's the deal. I will put the laparoscope into your abdomen. I will look from the inside and I'll see how nasty this thing is. And if it looks good, then I'll back out. I'll make my little fasciotomy and slide in and put it in and blow it up, and I can actually look and check and see how it's going." Then I could do that. And I must have done that four or five times, but, you know, we're talking thousands of operations, so it's pretty uncommon.
Dr. Randy Lehman: [00:30:27] Yeah, I like your theoretical situation where a patient has a known bilateral inguinal hernia and they had a radical prostatectomy and you did that and there's just adhesions everywhere. Would you do a bilateral open in that situation, or would you stage them and do one and then six weeks later do the other?
Dr. David Farley: [00:30:52] Good question. I would do them both open. I mean, part of that's my practice. I don't live in a smaller town where this person may be coming 10 miles. You know, I got somebody coming from the coast or Canada or wherever. You know, the truth is, at the Mayo Clinic, 75% of all people come within 150 miles of Rochester. But I don't really want people going back and forth.
So I would do bilateral open repairs on that person. Good question.
Dr. Randy Lehman: [00:31:20] All right, great. Well, let's move on to the next section of the show that's called "The Financial Corner." I just have a bent towards personal finance. I think it makes you more of who you already are. And assuming that most of us are relatively altruistically motivated, I think if surgeons are more in control of their finances, it's a good thing overall for rural surgery and surgery in general. So I'd like to ask if you have any particular money tip that maybe you wish you knew earlier or that something that worked well for you or even a financial mistake.
Dr. David Farley: [00:31:51] I'm pretty lucky. My father was a saver, was a budgeter. I like Dave Ramsey. I like paying off debt. I don't like to pay other people money any longer than I have to. If you're going to get a mortgage, I like 15 years or less, and if it's a 15-year, I want to pay it off in six or seven sort of thing.
But I think Dave Ramsey's point is he oftentimes says, "Live like no one else so you can live like no one else." Meaning, hey, you're skimming the bone. You know, you saved up money. You worked. I mean, I worked through college, I worked through medical school, I worked through residency, moonlighting, whatnot.
So come off of that, to not have some of the trainees coming through now have over $500,000 in debt. That's a pretty nice house. And I wouldn't want that debt coupled with a house mortgage payment. So get rid of the debt. And then from a savings standpoint, if the company or the hospital or the institution has a 403(b) or a 401(k) or has any sort of matching, I'm signed in. I want... What's the max? You give me 7%? It's free money. I want the free money.
I will be happy to do my thing, but I want your free money. And then my wife and I are good savers so that we can, you know, when it comes time to buy something, she would always tell me, "You tell me never to settle. Don't settle in the operating room. Don't settle, you know, for the address or whatever." Dang, she's right. I don't want her to settle.
But, you know, you've saved for this and, you know, save for your kids for college. We have three kids, and we saved up every penny so that they don't have any debt. Now, that may or may not be a good thing for them, but I like the idea of getting rid of debt, saving money. And as far as investing, I'm a pretty aggressive investor. I'm still not spending any of the money that I've saved.
And so I'm weighted toward the stock market more than I probably should be. I'm now in retirement. I'm 63. And I'm actually coming to the point where, dang it, I gotta... I gotta cash out. And some of this stuff is accrued, you know, and it's like, all right, should I give some stock away and just, you know, be altruistic as you suggest and not get hit with that? But that's what I got to offer. I don't expect or assume to be an expert, but I think there's something to buy and hold them. I'm not a big buyer-seller guy, and I am big into savings and getting rid of debt.
Dr. Randy Lehman: [00:34:30] I have one follow-up to that. So it does seem that when the time came and Epic was hitting you and that extra 45 minutes a day is too much to bear that you gave yourself options by living like no one else. So later you can live like no one else. So at what age did you retire? When do you think you could have retired?
Dr. David Farley: [00:34:53] Great question. So I retired at age 59. From a financial standpoint, it was a mistake. The Mayo Clinic, the way their pension works... I had 25 years in. I should have worked five more years because the pension that I'm drawing now, it's fixed. It's not that good, quite honestly. And it would be double if I would have spent five more years, and that would have been really nice. But I'm still not five years out from my retirement, and I've been really enjoying what I wanted to do. I think I probably could have retired at…
I'm just trying to think. My last child got through college in 2016, and she was well on her way at that point. Financially, we knew she wouldn't need any more money. So I probably could have retired when I was 52, 53, comfortably, you know, having confidence that this is going to be okay.
But again, take a look at what your situation is. I don't know anything about your situation or the people that are watching this podcast, but for me, at the Mayo Clinic, 25 years got to a nice pension, but 30 years was a lucrative thing. And that's kind of the... What do they call that? The golden handcuffs [Uncertain] or other at the Mayo Clinic, we kind of keep people hanging on for five more years. Yeah, right. Yeah, sure.
Dr. Randy Lehman: [00:36:24] Well, here's the thing. My situation now is very good because I've been extremely aggressively investing and saving, and my personal spending has been like, next to nothing. And I also didn't let a good pandemic go to waste and invested really heavy during that period when everybody else was scared. And so if I wanted to retire right now, with my current standard of living, I'm good, and I'm 35.
But that's different. I mean, I don't think a lot of people are in that situation. The other thing that I was able to do, speaking of rural surgery, and you mentioned somebody having $500,000 of debt... I think that debt reimbursement deals are very common with rural hospitals in particular right now. And so if you come... So, first off, I would recommend minimizing your debt, because I knew people that were medical students and they were living in luxury condos in Cincinnati and living like they were a physician already, but doing it on a loan.
And come on, guys. Like, let's use our heads a little bit. Minimize your debt as much as you possibly can. Don't take out debt for all of your tuition, if you can, if you can take family support, do it, you know, all that stuff, work a second job. But then once you minimize that and you get out, there are places—they may not do $500,000, though, but maybe they will, I don't know.
And so calling some rural places and seeing if you can include debt repayment as part of your initial contract, I think is a great strategy. But then once you get the debt gone, I did that, I guess. And so my debt was gone before I left residency because I was paying it off through residency with a stipend with the place I committed to. And so, you know, living frugal and investing. But the thing is, at the end of the day, I'm a board-certified workaholic.
Dr. David Farley: [00:38:08] Yeah.
Dr. Randy Lehman: [00:38:09] So I'm not planning what's the right time for a surgeon to retire. I'm definitely not trying to get on the bandwagon and say all of you guys should retire early or FIRE or whatever, because we actually need the surgeons—the thousand or so general surgeons that we're creating every year—to come out and replace the workforce and maybe not even retire at 59. But you can then be in control of your practice. You can do things in a way that it doesn't... You can have life and your surgery, you can be more efficient and, you know, not have to take the bureaucratic stuff. You can kind of push back against that a little more, especially if you're able to walk away from it.
Dr. David Farley: [00:38:52] Agree completely. I think we've had, you know, I probably had a couple dozen trainees that were in the military and had their cost paid and, you know, came out with a surplus of money. More power to them. Key point, I don't want you to be a workaholic. I was certainly a workaholic, 80-plus hours for 30 years. Having said that, I coached my kids' Little League teams. I was there for the bowling tournaments. And you know, I was trying to be everything to everybody, but probably shortchanged my wife a lot. And if I had to do it all over again, I would try to refinagle that.
And you know, it depends if you have kids or not. It's great that you have enough money that you're ready to retire at 35, you love what you do.
Dr. Randy Lehman: [00:39:42] 35.
Dr. David Farley: [00:39:43] 35, right. That's awesome. You know, at 35, I had one child, another on the way, and wanted more. And a child is going to cost you about $300,000 to get to age 18. And if you get three of them, okay, you got to spend a million bucks. Your retirement just got pushed back a little bit, and everybody wants to do that in different ways.
Some people burn out. I did not feel burned out. I was frustrated, and I wanted more time with my bride, and I didn't want to spend more time typing on a computer. I was still doing four to ten operations every other day and teaching every Friday, all day, and it was great. And I miss the education part. I don't miss the bureaucracy and the Epic and that part. I miss taking care of patients.
But I'm really quite busy doing what I'm doing and happy to do it. And I'm not sure what number you need to be comfortable. You might need $10 million to feel comfortable. Somebody you know, as you said, you're living pretty frugally, then, you know, most people, if doing what you're doing, could probably have $1.5 million, and, hey, they're going to be just fine. That may not be true if you've got kids going to college and you want to help out. I felt like that was important for my wife and I to do that. Right?
Dr. Randy Lehman: [00:41:08] Yeah. Yeah. And there's also a piece of that, which is I'm planning to keep working, too. So, you know, maybe I'm being a little flippant, but overall, yeah, it's a great position to be a surgeon and have the power to be able to get that freedom quickly and do the things that we've both been able to do.
Dr. David Farley: [00:41:25] So wonderful.
Dr. Randy Lehman: [00:41:26] So the topic that I do next is "Classic Rural Surgery." And that's something that's so classic for rural surgery, but for you, not having necessarily had somebody trade you chickens for surgery or whatever, but you've trained a lot of rural surgeons. I'd like to take this opportunity to use this segment of the podcast and talk about training. And when we were talking preparing ahead of time for this, you brought up effort and feedback. And so maybe you could just wax eloquently on that for a short period of time and I could ask a few follow-ups.
Dr. David Farley: [00:41:58] Sure. So after giving a couple hundred talks at Mayo and across the planet, my passion is education, and that's what I like to talk about, because I like to improve, I like to learn, and I want my learners to improve. And my goal was always to take the most dangerous surgeons in the world, the people that just graduated medical school and start an internship and make them better.
And so it took me 30 years of working with that and it was a long time. But my eventual mantra was going to be, I want you to be better, to start so you can do more in the operating room and be safer in the operating room. And to do that, there's two things that need to happen. Number one, the learner needs to put forth effort. The rural surgeon needs to put forth effort. Somebody wants to be a better dancer, needs to put more effort into being a better dancer or golfer or surgeon.
And then how do we do that besides the effort? You gotta have feedback. Somebody, some friend, some colleague, some coach, some mentor, a wife, a spouse, a colleague, a nurse, a medical student, or most importantly, the learner themselves can give themselves feedback. So if we're talking about rural surgery, so I'm going to not talk about golf and dancing, but if we're going to be good at rural surgery, that entails a lot of stuff, you know, how to talk to a patient, history and physical exam. That's not kind of my schtick. I'm talking about technical skills, I'm talking about judgment. How do we become a better, safer surgeon? So the learner has got to put in more effort.
What does that mean? If you read a chapter in a book, five pages, and you read it and you read that tonight, you close the book and you never look at it again, it's very unlikely that you're going to have any long-term retention from that. I'm sure maybe you did it in college. I certainly did it in college and medical school. I highlighted that five-page chapter, I highlighted the key things.
And so I would read it and the next day I would read the highlights. "Yep, I know that." And then maybe a week later I'd read those highlights again. "Yep, I know that." And then maybe it would come to the ABSITE, the American Board of Surgery In-Training Examination. Or maybe it would become Dr. Saar or Dr. Lehman or Dr. Somebody's going to ask me a question on that and I can say, "Ah, it's at the bottom of the page and it's highlighted." What the hell does it say? I don't know that.
And so my point is the learner's got to put forth more effort. You got to get your brain to work. Highlighting, reading highlights—the brain doesn't work at all. It's almost useless. It's better than nothing, but it's almost useless. What would be a better thing? Read the five pages, close the book and tell your spouse or tell your scrub nurse while you're doing something else or one-on-one: "I just read a chapter on thyroidectomy. I want to tell you a little bit what I learned."
And what I learned is, and maybe the first time you read the chapter on thyroidectomy, "There's three veins. There's a superior, a middle and an inferior thyroid vein. There's three veins, but there's only two arteries. But there's sometimes a thyroid ima." And that's all you get out of it. But that's better than reading the highlights. You have to generate things, the more you can generate.
So if Randy Lehman is my intern way back five years ago or however long that was, and we're doing a thyroidectomy and he wakes up at 5 in the morning and he's taking a shower, if he's into it, if he's into learning, I'm hopeful he's read the night before and he's got Farley's cheat sheets and has 21 steps on thyroidectomy while he's shampooing his hair. "Curvilinear incision. Divide the platysma, separate that up. Median raphe. Down in the midline. Two Kocher retraction."
That is generating learning potential for long-term learning. And you can see this, and I saw this over and over again. And I can remember one of my trainees, we did a thyroid on a Monday morning. And I usually put those first cases on a Wednesday morning and a Friday morning. Good training, bright training. Nothing wrong with the training.
And on the first case, he'd never done a thyroidectomy before. And so I let them do what I thought they were comfortable. They made the incision, they divided the platysma, got in the midline, they didn't hit the anterior jugulars. They got the strap muscles out of the way. They put the clamps on the edge of the thyroid, the Kocher clamps and rotate it up. And sort of the first step is always for me is let's divide the middle thyroid vein. It's a safe thing.
I don't know how many times, if I did 500 thyroidectomies, I'll bet 100 times we had bleeding from the middle thyroid vein, mea culpa because I got a trainee doing it and I would let them do it. And I said, "We're going to ligate in continuity." Okay, what does that mean? Well, right angle comes in, we pass a 3-0 silk up. A right angle comes in, we pass a 3-0 silk up, we hold them up. You tie your side, I tie my side. You tie it a little bit this way, I tie it this way. When we get done, you hold both of them, cut in the middle and cut to two stitches. That's ligate in continuity.
We did the same thing on Wednesday. And I said, "All right, what do we do now?" Because now we're Kocher's up, thyroid's up. "I don't know." I said, "What do we need to do?" "I don't know." And just sort of paralysis. I said, "What about this blue thing that's here?" "Yeah, yeah, we need to take that out of the way." I said, "What is that blue thing?" "No idea."
"What do we need to do to it?" "No idea." If I helped him one more time through this thing. Middle thyroid vein, ligate in continuity. We got to Friday, same thing, same right thyroid lobectomy. Got to the point, put the clamps on. "What are we going to do?" Didn't know what to do.
And so in my mind, Randy, I failed. I failed that young man. I didn't expect enough coming in at the end of the case. If I really wanted to know that I should have stepped back. If there was five minutes or the next case we were scrubbing, I could have said, "Hey, how do you get rid of the thyroid vein?" "Well, you ligate in continuity." "Well, take me through that." And if I had done that and I did it on Wednesday again, when I came to Friday, I would have had a better learner and better prepared.
And so that's what we've tried to do in the sim center. And I wanted to comment, if you've got listeners out there, we had a nice model for TEP hernia that you could simulate. It's an inanimate model. It doesn't look completely like the real thing, but it gives you a sense of working in a softball-sized space.
But that's what I mean about effort. You got to put effort in and it's doing more surgery or reading videos, looking at videos, or if you record your TEP inguinal hernia repairs, which I hope you do, I hope others do, I hope you go back from time to time and look at them. One of the best surgeons I ever trained is now was my boss is the chairman of the department at the Mayo Clinic. He's one of the few surgeons that I know that has gone back and looking carefully at his laparoscopic stuff, doing laparoscopic Whipples, laparoscopic hepaticojejunostomy.
And he knows when he screws up and he's the best critic of it. He asked me to look at it early on. Yeah, but he's better at it now and he's really good at what he does and he's put more effort into that and then getting feedback. Well, he's getting feedback because he's looking at it and he knows that blood looks like stink and he made a mistake and he's given himself feedback.
But there's other people. The nice thing about the Mayo Clinic is there were visitors all the time and people from Japan or Germany or whatnot would come in there. And I'm doing a TEP hernia. They don't speak the language very well, but I can see them nodding and I can see them shaking their head and I realize they know what I'm doing and they don't like it. And so I said, "Time out. Can you tell me what it is that you don't like?"
And the English would be, be careful. I don't want to offend anybody. But it would be broken English and "No, no, no, no. You need what you know and ah, why, why do you do it that way?" So... And sometimes I agreed, sometimes I disagreed. And the cool thing about having a trainee at the Mayo Clinic, somebody like you, your previous rotation might have been with Dr. Nagorney [Uncertain] or Dr. Sarr or Dr. Expert. And I would always ask trainees, "Hey, is there any other way to do this?"
"Well, Dr. Nagorney likes to do it like this," and I'm all ears. He was my program director. It was like, "He does it like that? Why does he do it like that?" And somebody like you is sharp enough to pick up and says he does it like that because it's less tension and less likely to pop the stitch and make it bleed. Okay, I just got some critical feedback and critical learning that is a better way for them. So effort and feedback, that's what it all comes down to.
Dr. Randy Lehman: [00:51:11] So beautiful thoughts, I have a couple questions. So one time when I was a third-year medical student in Cincinnati on my first rotation in general surgery, I was doing a gastric perforation from ulcer disease, but it was in the fundus. Kind of weird, but pathology didn't end up... It would end up being benign. But I had a great start to the rotation. I was putting a lot of effort coming in at 4 in the morning, you know, doing all the things on trauma surgery.
I was with, I would say, just a guy that had a very good respect in the resident that was sort of taking me under his wing. And I was having a really good time with him. I was staying late. It's like 7:00. We're doing this call case. I could have gone home if I wanted to. I chose not to, of course. And I'm in the middle of this case with them.
And it was a young junior staff. Everyone was in extremely good spirits, relaxed, and I was just loving it. And we're getting started and we find this huge hole in the fundus. And the staff turns to me and he goes, "What's your name?" And you know, "Randy Lehman." "Randy, you ever heard of a Nissen fundoplication?" And I hadn't. And so I said, "No, sir." And I just remember the resident just spinning and looking at me and this disappointment in his eyes and just how painful that was.
Better than lying about it, you know, obviously you gotta be honest. But then he said, "Okay, well, anyway, this is a Nissen fundo perforation." [Uncertain] And he's just trying to make a joke. And I'm not able to participate in the joke because I didn't have that fund of knowledge.
So what I tell students, because you're great at training interns, and that's what you kind of spent your whole career doing. And we really appreciate it. But there's trainees that are above that level and then there's students. And so when students are going on a clerkship, what I learned from that is buy one of these superficial review books, throw-away kind of paperback books. That is honestly not going to be 100% accurate. And it's probably a little out of date, but it's going to give you a framework where everything goes.
Open that book and read it in a night and just read the bold stuff. Because what I tend to do when I read is I bog down on the first page and I get to the end, I didn't remember anything and I reread it again and then I'm done. So instead, just skim through it. So, you know, wherever now you remembered what page that thing that you're trying to remember was on, but you didn't remember the details of it.
Now they'll actually remember that. And then you have to do a lot of just-in-time learning. So your trainee that was doing the thyroidectomy was probably not reading about the thyroidectomy or watching the videos the night before or, you know, I would do a lot of Medscape in the bathroom before surgeries, you know, reminding myself of all the steps.
Trainees need to hear this and know this, because if you come and you just show up and it's like, "Okay, we're going to do this breast case, breast cancer case with Dr. Whoever." And so what's this patient? "So she's ready to be, she's ready to go." And he says, "You know, this is a male breast cancer patient, right?" That's not the place you want to be.
Dr. David Farley: [00:54:55] Okay.
Dr. Randy Lehman: [00:54:56] And you don't want to be not knowing what basic surgeries are. So you can't even participate in the joke because it's not just about showing up and working all the hours and trying hard. It's actually you got to know some things and that prior preparation that really kind of sets you apart. So that's, I think that's somewhat of what you're saying with effort.
And then last thing is if you follow up afterwards, like a three-hit plan about the surgery—do the surgery, afterwards think about it and do the feedback thing—do you have any evidence for that or any studies? Because intuitively it seems like that's the right thing to do. But I know you were also kind of evidence-based as you went through.
Dr. David Farley: [00:55:37] There's a lot of studies out there that show you, you know, if you give a PowerPoint present how to give it so people actually retain more. And most of the studies that I know of talk about the best learning happens when the learner themselves turns it back on themselves. What do I know?
"Oh, I got five minutes, I'm going to operate something on the stomach," and I quick look at the anatomy and I didn't look at fundoplication. Hey, that's okay, you know, and hopefully the people that are teaching realize that's okay. But if you get an opportunity to read more and quiz yourself more so that you don't forget, you know, and do the highlight thing, that's no good, you lose that bit.
And I guess I'll give one plug for a book that we created. It's called "Mayo Clinic General Surgery." It's published by Oxford and it has videos and it has one page of text. And it has text, let's say adrenal gland and it says embryology, it says anatomy, it says physiology, it says surgery, it says pathology, it says complications and it says whatever. And there's a couple sentences on each one of those things, but within each of those sentences something's underlined.
Well, that's a link or this is a movie, this is a video if you want more because on the stomach it will say someplace "fundoplication." And if you'd have clicked on that, you'd have gotten the joke. You might not have been well-versed, but it's a digital kind of a book. I think it goes for $140 or something. And there's been a lot of people across the country and across the world have sent me a note and said, "This is really different. This is really helpful."
But it's not being marketed greatly. And I realize that's an expensive dollar amount, especially for trainees, but if you're interested in general surgery, I think it has 30 different categories. Adrenal, thyroid, parathyroid, hernia, breast, colon, rectum, you know, that sort of thing. And it's broken down the same way. And it has a lot of video access to it. It has a lot of great Mayo illustrations.
And what you're talking about, if you're looking for something to do the night before, which I hope everybody is, you know, and if you're a rural surgeon and tomorrow you're going to do a laparoscopic adrenalectomy, you should review that. You should. Hey, and we can watch and there's a Farley video or the Lehman video, or you can go to the Internet. You can find all sorts of stuff. It may not be good, but if you look at it honestly, I think you can actually generate in your brain: "All right, I learned I'm not going to do that. And that looks pretty cool. That guy made a good point. Or she's really dexterous there. I've got to remember that."
Dr. Randy Lehman: [00:58:24] So we will put a link to that in the Show Notes. Can you say it one more time?
Dr. David Farley: [00:58:28] "Mayo Clinic General Surgery." It's published by Oxford out of London. And I will find that Show Notes.
Dr. Randy Lehman: [00:58:37] Our last segment is supposed to be "Resources for the Busy Rural Surgeon." I think that works unless you had something else. But, I mean, I find myself, you know, my institution buys us a subscription to UpToDate. And I find myself on UpToDate a lot, you know, looking up different things. And I just... I feel like there's more to life than UpToDate. You know, we have so many great organizations, American College of Surgeons, SAGES, and then things like this. Those are the resources I'm trying to bring out and make accessible to people. You can't look at all of them.
Dr. David Farley: [00:59:07] But, yeah, the one thing that I will tell you about, it's not out yet and it may never come, but I'm hopeful it will. Dr. Mike Sarr and I are working through the American College of Surgeons on a project called "Operative Decision Making." And quite honestly, I'd like you and any of your rural colleagues, if you have some videos or illustrations to send them to Dr. Farley at david55farley@mail.com. We are taking cases. The two cases that we've gotten, we're trying to pass it through. The American College is making a decision. We got somebody that comes up with a CT scan that's got a right adrenal mass. How do you work that up? How do you operate? Should you operate? When you do operate, what do you do?
And if there's problems, what do you do? And it's a platform that a rural surgeon, community surgeon, any surgeon could be—medical student, could be trainee, but it's catered to community rural surgeons in practice to say, "All right, how do we do this?"
And it's not the be-all, end-all, but it's an idea to say, okay, here's a case on difficult laparoscopic cholecystectomy. I bet you've had a bunch. And we ask you questions and we say, "All right, what would you do next?" And Mike and I have gone through this and we said, "You know what? The learner could probably give us six different things. I think I'd open, I think I'd do a subtotal cholecystectomy. I think I'd put in another port. I think I'd put in whatever."
And we've got feedback for each of those answers. And you click on the "I'd immediately open" and we say, "Okay, that's not unreasonable, but in the interest of education, we're going to push you a little bit. You haven't burned any bridges yet. It's scarred, it's stuck. You haven't got the critical view of safety, but there's a couple things that we think that you can do." And so we're going to challenge you some more. And it's pretty engaging and I'm hopeful it'll be useful and valuable and financially valuable so that you get credits for whatever you need for recertification and hopefully it passes on. You know, good insightful learning.
Dr. Randy Lehman: [01:01:13] It's like a choose your own adventure.
Dr. David Farley: [01:01:15] It is, it is. And most of the adventure, it's pretty straightforward. But, you know, the adrenal case that we got, it's a Farley case. And I'm not shy about hiding things that didn't go perfectly well. I never have been, never will be. And it puts a learner in there. The learners that we put in there all of a sudden said, "Oh my, oh, I don't know what to do." And one of the choices is to say, "I don't know."
And sometimes we couch in, "Well, think about this or that." But other times we said, "Sorry, not going to accept that. You got to do something. Right now, this is a bad problem with this adrenal bleeder or crisis or whatever it is." And I think surgeons will find it useful, engaging, and, I hope, valuable.
Dr. Randy Lehman: [01:02:02] Yeah. So I have you still with me, and I'm going to be selfish here and do a very brief, but actually practical "How I Do It" again. Thursday, two days from now, I have a J-tube. So a patient who has esophageal cancer. And so instead of putting a G-tube and potentially ruining a conduit, they need a J-tube.
So I have maybe done three, I think, since I've been out. So it's not a common thing that's needed. But when you need the J-tube, you need it. First one I think I did open. Second one I tried laparoscopic. And what the issue I was running into was I was stitching laparoscopically with a 3-0 or... I can't remember if it's a 2-0, whatever. I was using a regular stitch on an SH needle and then tying to the, you know, roof, basically to the anterior abdominal wall, trying to do my Witzel tunnel.
And I couldn't get the stitch to stay even with the surgeon's knot because the weight of the bowel would not stay up there and kept falling down. I farted around with it for too long. So I decided to open on that one. I just did one last week, actually, on a locums rotation in Tomah [Uncertain], which is this little life hack that I have, and I love it. But basically the patient had been diagnosed with obstructing esophageal cancer the day before by the surgeon there.
Then I come on the next day and we did the laparoscopic J-tube together just to be cleared. Laparoscopic J-tube—one less RVU than open J-tube. So that's... That's an oversight by somebody, but whatever, do the right thing and have fun. So I got that one done with a surgeon assist. And the way I did it is I used a suture passer like you would do with the ventral Gore-Tex suture for the hernias. And I put one on each end and then I made the hole, you know, that was able to hold it up. And then I did my Witzel tunnel over the top laparoscopically.
I now—I was like, I'm never going to have another one for another six to 12 months. And I just diagnosed somebody yesterday with esophageal cancer, and they're asking for a J tube. So I'm going to put that in. My plan is to use the Endo Stitch. Did you ever use that device?
Dr. David Farley: [01:04:16] I have. I have not much.
Dr. Randy Lehman: [01:04:19] I think it's good. I think it'll make it easier for me to sew the [whittle (little)] tunnel. And then I was going to use my suture passer on the ends. I was just wondering—if you were going to do a J tube, did you do any of those laparoscopically? And do you have any practical tips for me?
Dr. David Farley: [01:04:34] Again, take this for what it's worth. Five years with no surgery, and I'm going to bet that the last five years I didn't do a J tube. So I'm at least 10 years out. Having said that, I think planning and strategizing—making your measurements and figuring out, all right, where is this going to sit? How is that, you know, going to angle in? You know, most times we always talk about going straight in, but sometimes a J tube lies better with a little bit of an angulated path.
And I was just thinking, when you said it was too heavy, I remember that very well. Remember that very well. And at one point I had to put in—I said, you know what? I'm at the Mayo Clinic. I have the luxury that you may not. I got another port. [PossibleDiarizationError] I'm going to put a 5-millimeter port. I'm going to ask my medical student to take this grasper. I'm going to put it up here and hold this bowel up and take the tension off of it.
Because sometimes tension is a great thing. You got cautery or dissections. I love tension. I don't like tension when I'm trying to suture that thing up. And so that would be a simple sort of thing. It costs you another port. But, you know, sometimes those J tubes can take an hour and a half. And it oftentimes could have been a 12-minute operation. Having said that, with a young learner, they can pass, point, and poke a hole right through the bowel.
So I think for me, I always try to put in those four stitches around the entry, getting my thing in, balloon testing to make sure it was in the lumen. And then I would always sort of pull them up. Roger Dozois was a wonderful colorectal surgeon that would sometimes have a patient that he was doing a low anterior resection. He would have all these sutures down there. But it was really kind of a neat thing, like a parachute. He said, "We're going to parachute this thing down."
And it was sort of a nice move. In my brain, I can see it. I don't know that I can describe it. But the four points around this jejunotomy—you sort of bring that thing up, and then the camera person's got to back up, and you can't see it. You can't see if they're all up there. And so then you take the one that's closest to the camera and let that go down. You tap it, and—oh, yeah, I can see the tube coming into the bowel. And the back one's up where it's supposed to be. And the other ones, pull them up slow. Yep. Right where they're supposed to pull it. And now all four of them are there. And if nobody moves, they're where they're supposed to be. And you can tie whatever it is that you're doing with relative confidence, especially if you have the tension off the back side. So I don't know if that's helpful or just.
Dr. Randy Lehman: [01:07:19] Are those transfascial stitches?
Dr. David Farley: [01:07:21] No, they were intra-abdominal. They were intra-abdominal.
Dr. Randy Lehman: [01:07:26] So you're pulling up on the stitches?
Dr. David Farley: [01:07:28] Now you're pulling up on the stitches, but. And this is where you might need two ports. In my mind, I'm thinking to lift that bowel up, and the camera gets a sense of it's up there. And you can tie it or you can crimp it down. I remember some of those J tubes had a gadget you could sort of slide down, and it would crimp it up. Or they had T bars too. That's what it was, Randy.
They had those little needles, and you pushed it through, and out popped this T. And now you're inside the lumen, and you pull the T up to the thing, and then you pull the wire out, and you would crimp it at the skin. That's what it was. It wasn't intra-abdominal stitching. It was the T bar. And I don't know if that even exists anymore.
Dr. Randy Lehman: [01:08:17] Yeah, I know. I used it during training once, but it wasn't the slickest thing. And I think I'm just kind of developing this—you know, how would I like to do it? I have to do some videos, and it might be worthwhile for somebody else to see at some point. Yeah, I use the Endo Stitch for my incisional hernias, and I'm pretty good at it. So, you know, use what you're good at, I guess.
Dr. David Farley: [01:08:37] Yeah, absolutely.
Dr. Randy Lehman: [01:08:38] Absolutely.
Dr. David Farley: [01:08:38] And send me a video. I'd love that. I'd love to put cases like that out for, you know, community surgeons. You know, you're the expert. I'm not the expert, but I can look at stuff and say, "I don't like that. I don't like that move," and make a comment and whatnot, and then make people generate their own learning. So I'm all in.
Dr. Randy Lehman: [01:08:58] Yeah, well, I really appreciate that. And I'm just so thankful for the time that we've had here together. And also, just all the effort that you put into my training and so many other trainees, but particularly, obviously, mine. And the community—I know for sure in my town—is benefiting from you. So, to your point, you know, you're thinking about it right in the way that your impact on the world is greater and amplified because you spent all that painful time training us. So, thank you so much for coming on.
Dr. David Farley: [01:09:28] It's my pleasure—my pleasure to work with you and all the rest of them. And I wish you and your listeners well.
Dr. Randy Lehman: [01:09:35] Thank you very much. And that's right. Thanks for joining us on this episode of the Rural American Surgeon. Catch us next time. Take care.