Episode 12

From Residency to Rural with Dr. Ben Mundell

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.

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, or primary care provider—or simply someone interested in healthcare for rural America—I'm glad you're here. Now let's get into the show.

Dr. Randy Lehman: [00:00:46] Hey, everybody. Welcome back to the Rural American Surgeon Podcast. I'm your host, Randy Lehman. I've got a guest with me today, Dr. Ben Mundell. He is a general surgeon who just finished residency about three or four months ago and recently started his new job as a rural surgeon in the Eastern Sierras. Ben, thank you for taking the time to join us today.

Dr. Ben Mundell: [00:01:06] Thanks, Randy.

Dr. Randy Lehman: [00:01:08] I've got your quote of the day, which I'd like to start with. I really want this podcast to be inspirational for my guests. Today's quote is, "Passion is the dream you hold so dearly you're embarrassed to say it out loud." I don't know where it came from, but this podcast is part of that for me.

My whole practice is so deeply part of my being. I just want rural surgery to be successful—for you, for me, for Ben, for the patients, for the communities. It's something that I really care about. You have to have something you're passionate about, something that gets you up in the morning. It inspires me to meet and talk with people like Ben to help grow this community.

When you're out there, man, you're in the thick of it. Sometimes you can feel like you're on your own—and you sort of are. With that, let’s introduce Ben. So, Ben, I know you from training. He’s a Mayo product; we met at the Rochester, Minnesota, Mayo Clinic. Before residency, Ben was actually a vet. Thank you very much for your service. He flew jets for the Air Force for seven years after college, then went back to medical school and onto residency.

Ben did his first three years at Mayo Rochester and finished his last two years at Mayo Arizona. Now, two months ago, he landed in the Eastern Sierras in California. He’s joined two other surgeons in a three-surgeon practice at a critical access hospital. Thank you, Ben, and welcome! I’d like to start by discussing the opportunities you’ve found there. Tell us a little about this hospital.

Dr. Ben Mundell: [00:03:04] Yeah, so it’s in Mammoth Lakes, California, which is right in the center of the Eastern Sierras. It’s a great hospital from a leadership standpoint—really financially stable. We have the benefit of having a major ski resort in town, which generates a lot of trauma in the winter, from what I’m told, and a lot of visits in the summer too.

We’re about 20 miles from the eastern entrance to Yosemite, so there’s a heavy tourist industry. The town has about 8,000 residents, but it grows to 30,000–35,000 on the weekends. Many of the other hospitals in the Eastern Sierras haven’t been doing well—they’ve closed down or struggled financially, often because they don’t have surgical services. So, we serve as a referral center for everything, from a couple of hours north to a couple of hours south. The closest place to us is Reno, which is about three hours away.

North Vegas is about five hours from us, and Los Angeles in Southern California is about six hours.

Dr. Randy Lehman: [00:04:16] Yeah. Do you think that the places that have closed haven’t had surgery, and that’s part of the reason why they weren’t able to stay viable?

Dr. Ben Mundell: [00:04:25] Yeah, and I think that, you know, some of the areas are kind of hard to recruit for. And then I think, yeah, they’ve just relied only on locums. I think that’s part of what I’ve been told—they haven’t had reliable, consistent surgical services. We also have the benefit of having a really great orthopedics group here, which probably about 10 years ago saw a vision of expanding elective care, not just doing trauma.

So we’re trying to follow suit on the general surgery side and sort of capture more of the patients they’ve been seeing—that same population from, you know, farther away, two or three hours out, who don’t want to go to the bigger cities. Mammoth is a reasonable place for them to come to.

Dr. Randy Lehman: [00:05:10] Sure. So I trained in the Mayo Rural Surgery track, and I sort of self-identified. I wanted to go back home to my hometown in Indiana, so I sought out that training. Now, you were in the basic general surgery track, and people in Mayo can go in many different directions, but most go hyper-specialized city practice.

I don’t just do breast surgery—I only do left breast surgery, you know, like it’s crazy. But for you, how did you find yourself going to rural surgery after ivory-tower-type training?

Dr. Ben Mundell: [00:05:44] Yeah, no, that’s a great question. So I think even in med school, I knew that I wanted to probably be in a smaller practice, at least a community setting, you know, a town of 100,000 or less, and possibly rural. I did a family medicine rotation in med school out in the health system. The family medicine doc out there did colonoscopies, EGDs—a little bit of everything.

He even sort of ran his own little urgent care out of his family medicine clinic. I knew I didn’t want to do family medicine, per se, but I wanted to be in a place where I could use the full breadth of my training. Dr. Stulak, our program director at the time, was also the clerkship director. He said, "Go either way—the rural track or the basic track. Either of them are good."

But I think coming out of Mayo med school, I sort of got pushed a little bit to not do the rural track for whatever reason. I picked up a few of those rotations during residency and really enjoyed them. After doing those, I knew that was what I wanted to do—be a community or rural general surgeon.

Dr. Randy Lehman: [00:06:54] How far into your training did you identify this place in Mammoth where you’re now practicing?

Dr. Ben Mundell: [00:06:59] Yeah, so I didn’t find this until the end of my fourth year or the beginning of my fifth year. That’s when I really started looking for jobs. My wife’s a dermatologist, so we obviously wanted to find jobs for both of us. We have family here on the West Coast, so we started looking up and down the coast for places that would be reasonable for our family and close to family.

As it happens, my brother-in-law is one of the orthopedic surgeons here on staff at the hospital. So it was a great way to be close to family.

Dr. Randy Lehman: [00:07:33] Yeah, often there’s some specific draw, like a spouse, bringing you to a particular area. I just want to say I’m very proud of you for going to this location and for the role you’re filling. It’s very important and crucial on so many levels. I’ve talked about this before on the podcast, but basically, the one-to-one patient-doctor relationship drives us, and we love it.

But when you're a rural surgeon, it's more than that. You're not just a commodity—a surgeon just producing, you know, whatever gallbladder or hernia surgery you're doing. It's about keeping that hospital viable so people can actually have a hospital to be admitted to. It extends much further than just the case you're doing right there.

You're creating jobs for the community and enhancing the rural place. People who live in rural America, believe it or not, are choosing to live there. They want to live there. It's not that they can't move to the city. I mean, I was driving today through rural Wisconsin, and I was just thinking to myself, "Man, I don't understand how somebody would want to live in one of the three big cities in the United States."

There's so much green, creation, and nature around. You're in a beautiful area. I'm gonna have to get out there to Mammoth and go skiing. That sounds amazing. For sure. But I'm proud of you for what you're doing, so keep it up.

So Ben reached out to me, and he just said, "Hey, I know you're four years out into a rural practice. I have opportunities here at this new place, and I'd like to talk to you about how I could make this a success. What pearls do you have, pitfalls to avoid, and whatnot?"

I said, "If you have those questions, I'm sure there's a resident or young attending somewhere else who might have the same ones. Maybe they'll be able to find us. Why don't we record it?" So, again, I appreciate you coming on. Why don't I lead off with a little bit of what I've done, and then you ask whatever questions you need to get the information you need for your practice.

Basically, I started as a W2 employee at a critical access hospital in northwest Indiana. Four years ago, in 2020, I took that job. I actually signed a contract in my second year of residency. I knew there were loan repayment options you could do, and I had student loans from medical school only, but I wanted to get them paid off as soon as possible.

So I signed that contract and took a loan from the hospital that was paid to me monthly over a period of time. By the time I was done with residency, I had paid off all my loans. Then I owed the hospital four years of service, and that loan was forgiven paycheck by paycheck over the next four years. I paid taxes on that as if it was income during that time, but I essentially got four years of free use of the money by taking it as a loan.

I would encourage someone to take a deal like that if they’re a young resident because there are options. Even if it didn’t work out at that place or something changed, I think another hospital, especially a rural one, would buy you out of that. You can get the use of the money, but it’s up to you to actually pay your loans down. I did pay mine off—I didn’t spend that money, which would have been a bad mistake.

If you can get some advanced payment and make a commitment to a place, it’s worth considering. The other thing it helped me with was from my second year on, I always envisioned myself in that hospital doing the surgeries I would eventually do. That really helped me with the mental part of my training.

I remember being on vascular surgery with Dr. Kalra, doing a triple A. I said, "Okay, so this patient comes into my critical access hospital in extremis. What am I going to do?" Then we walked through how I’d do my incision, how I’d get my super celiac clamp on, and everything.

Now, four years out, I don’t know if I’d handle things the same way.

Dr. Randy Lehman: [00:00:00] I probably would do everything I could in the ER and not take that patient to the OR in my hospital, given the limitations I know about. Ben, if you find yourself in some freaky situation in the next couple of years, call my cell phone. If you’re driving into the ER, and it’s some crazy situation, and you want to know what I would do, call me.

It may be different because you told me you have two ICU beds, MD anesthesia, and some other differences. You have to make your own decisions. I don’t want to use patients as examples in an unrespectful way, but I can think of at least one case where I did the right surgical thing, but I’m not sure it was the right thing considering my surgical limitations.

You have to think about factors such as time. What are you doing with stabilization? Generally, it’s never wrong to stabilize a patient in the ER before transport comes. Trauma is a big one, but the case I’m thinking of was a bowel perforation from a strangulated hernia. When I walked in, the patient was dead—they were coding and vomiting, aspirating in front of me.

How do you handle that? It’s an extremely bad situation for the patient. You try to do everything to save them, but how much of that needs to be done right then? Of course, there were no flights because the ceiling was low. These are real-life situations I’ve faced, and you may face them too.

You have partners, but phones may not work, or they might be traveling. Having other people you can call is important. Feel free to call me anytime. I always have my phone on. I know you won’t abuse it, and it’ll be fine.

When I’m on call at this hospital, there are two other surgeons, and I’m on call one in three weeks for a week at a time, from 7 a.m. Monday to 7 a.m. the next Monday. I usually get between two and four consults per week. Often, I have no consults in a day. The most common consult I get is esophageal food impaction. By the numbers, appendectomies (appies) and cholecystectomies (coleys) are about on par with esophageal food impactions.

Strangulated hernias happen, but not as much as I expected. There’s a mix of other cases too—GI bleeds, small bowel obstructions, and occasionally ovarian torsions. Do you have OB at your hospital?

Dr. Ben Mundell: [00:15:45] We do, but yeah, it’s not always available.

Dr. Randy Lehman: [00:15:50] Okay. Are you on call for C-section coverage?

Dr. Ben Mundell: [00:15:53] No, they closed our L&D department around the time of COVID. The plan is…

Dr. Randy Lehman: [00:16:00] How far do people have to travel to deliver a baby?

Dr. Ben Mundell: [00:16:03] It’s about 45 miles down the road to Bishop, California.

Dr. Randy Lehman: [00:16:09] But, you know, with weather…

Dr. Ben Mundell: [00:16:10] Yeah, there’s always a possibility someone might not make it.

Dr. Randy Lehman: [00:16:14] These are all things anyone in a rural place has to think about—managing your resources. The last thing I want to discuss is thyroids.

I recently did a parathyroid case and managed a couple of other thyroid-related questions. I got privileges to do adrenal surgeries and have done a couple of thyroid cases too. I don’t have a nerve monitor or intraoperative parathyroid hormone monitoring, so I consulted endocrine surgery about it.

Dr. Randy Lehman: [00:00:00] You know, they said, "Well, you could do a four-gland exploration. That’s what you need to do, or use IOPTH. Those are your options." But I then talked to some other rural surgeons, and they said, "Yeah, that’s true. But if your resources are limited, do you really want to do a four-gland exploration when you have a localized adenoma?"

So I took out a localized adenoma. The patient did well without doing a four-gland exploration. At the end of the day, when those cases came up—like when a hiatal hernia is on my schedule, I’m excited. When a right colectomy is on my schedule, I’m excited. When thyroids came up, I was just uncomfortable.

And I did 50 of these during service in six weeks. It’s not that I hadn’t done them—it’s just that you will know in your hands what cases you’re comfortable with. You want to do things where you know you’re the person who needs to handle that case. Breast surgery is like that for me.

I’ve decided not to do thyroids and parathyroids. I definitely wouldn’t do an adrenal right now. But in the future, if I get a partner or a group and we grow, I’d love to scrub with someone with that specific interest. Maybe then we could grow that service line. But I’ve been focusing on growing other areas for now.

Dr. Ben Mundell: [00:18:10] Yeah, so when you went into some of these smaller hospitals that hadn’t done as much general surgery in the last year or two, how did you go about ordering equipment or getting them to get you the new stuff? I’ve come in, and some things haven’t been done.

They haven’t been doing much laparoscopic surgery here in general for the last couple of years. There’s no mesh I need, no tackers I need. I’ve had to look up actual order and stock numbers to try to find things. It’s way different from training, where you’d just show up for a case at Mayo, and everything was there.

I guess one piece of advice I’d give is for people to take pictures of all the equipment they use during training if they’re going to a smaller place. It’s really nice to have those on your phone to show supply folks what you mean.

Dr. Randy Lehman: [00:19:07] If you’re in training, print out op notes and put them in a binder or save them on a disk. That would be helpful. And like you said, the equipment you’re using—take pictures or write it down so you know what to ask for.

When you leave residency, take as many preference cards as you can with you and keep good contacts at your residency. Don’t burn bridges on your way out. I was burnt out by the end of it, but I kept enough buddies back there. For example, I once needed help with a two-messenger mixture for split-thickness skin grafts.

I didn’t figure it out until I had my first skin graft to do. I had to call back to the surgery area, talk to the charge nurse, and eventually get through to the techs. That’s something I should’ve noted as a chief resident but didn’t. You’ve got to prepare for those things.

I want to talk about two other topics. First is urology. Do you have a urologist at your hospital?

Dr. Ben Mundell: [00:20:28] We do, but one of them is retiring in about a month. He and I are doing a case together before he retires. The other one is kind of on his way out too. They’re not consistently up here.

Dr. Randy Lehman: [00:20:42] Is the case a combined general and urology procedure, or what is it?

Dr. Ben Mundell: [00:20:46] Yeah, so it’s a low midline hernia after a hysterectomy, and there’s a little bit of bladder that looks like it’s abutting, maybe coming into the hernia sac. I just want him around for backup in case there are any issues.

Dr. Randy Lehman: [00:21:02] Okay. Well, I was kind of asked by the hospital I was going to, because I said, "Here’s the rural surgery track. I have special training in OB-GYN, urology, ENT, plastics, ortho. I had rotations in all those things during residency. What are you currently sending out of your ER regularly that I could come in and help with—like add a service line to your hospital?"

Whether or not you need three surgeons, that’s the problem. Most places don’t need a full-time urologist, OB-GYN, or whatever. They need, like, 0.1 of an OB-GYN, 0.1 of a urologist. If you can have a general surgeon who can do a lot of the easy stuff—like hysterectomy, tubal ligation, vasectomy, carpal tunnel—I do all those things.

That is easily within your scope as a general surgeon technically, if you just have a little bit of training. To me, that’s one way to define rural surgery. But when I went back, they said kidney stones. So I do common bile duct exploration using the LithoVue ureteroscope, a disposable ureteroscope.

One thing I really like about this is if I break it, it doesn’t matter because it’s disposable anyway. Your regular ureteroscope costs, you know, 100 grand or whatever, so you’re really careful with it. It’s the same exact piece of equipment I use to scope the bile duct. Flexible ureteroscopy is technically less demanding than that.

There’s also judgment involved. Are you going to use a laser to break up a stone way up in the kidney that requires you to really retroflex to get at? Or do you focus on ureteral stones that are too big to pass and fail a trial of passage? That would be a huge value to my community if I could do that.

So I went back and did some ureteroscopy toward the end of training in the middle of COVID with the urology guys. Then I came out to my hospital, and it became very political and weird. I don’t really know all the details, but the same people who were asking me to do it were then making a big deal about it.

It became an ego thing—a whole ordeal. I ended up going down to Indy to shadow for three days with a urologist who specialized in kidney stones. We did 18 cases together. He agreed to retroactively review my cases by video and chart review. I had everything set up to be proctored.

But then the hospital said their excuse was, "We don’t have anyone currently privileged to do it, so we don’t want you to do it." They didn’t want to go through the process I suggested. I wasted all this time, and honestly, I didn’t care that much. I was just sincerely trying to help. That’s how it ended.

It made me feel like when I was buying a house after residency. I bought an $83,000 house in my hometown and set myself up for success in so many ways by doing that. But I called a bank and said, "Hey, I got this house under contract, and I heard about physician loans where you can get no money down and no PMI mortgage insurance."

They said, "Oh, yeah, we’d love to do that for you. We could lend up to $750,000 with no money down and no PMI. If you want to buy up to $1.5 million, we’ll lend with 5% down and no PMI." I said, "Okay, great. I’ve got this house under contract for $83,000, so you should be able to do that, no problem."

Oh, well, wait a minute. Actually, we’re going to have to get back to you. So then they call me back: "Well, you’re actually four months out from starting your new job, and our policy is we don’t do these physician loans unless it’s three months or less before starting your new job."

I’m like, all right, fine. I’ll just put 20% down and do a regular standard loan. Then they said, "We can’t use your future earnings for this. You have to use your current income." I said, "Fine, just use my current earnings as a resident. I’ll do a regular loan." Then they said, "Actually, you told us that job is ending, so we can’t use that income either."

That’s how it was. So I called my regular bank that I used for my apartment in Minnesota. I was like, "Hey, just let me put 20% down." I almost just paid cash for the house. It was such a joke. You find yourself in these frustrating situations, and you just want to have a sense of humor and not get as upset as I do sometimes.

Let’s move on to the "how I do it" section of the show. Ben, I’d like you to talk about the laparoscopic approach to inguinal hernia repair. So a guy walks into your clinic with an inguinal hernia. What are the pre-op things you’re thinking about? When do you decide between laparoscopic and open?

Dr. Ben Mundell: [00:26:38] Yeah, I mean, my default is probably laparoscopic. I trained with a few people who did it almost exclusively laparoscopic and one guy who always did them open. The conversation I like to have with patients is that there’s evidence suggesting less chronic pain with laparoscopic surgery.

Theoretically, those incisions are farther from the mesh, so there might be less risk of a mesh infection if there’s a surgical site infection. I also think the biggest advantage is the ability to assess the contralateral side. If there’s any question about a hernia on that side, you get a nice view.

Most people I know aren’t routinely opening up the inguinal floor, so with laparoscopic repair, you get coverage of spaces like the femoral and obturator regions with the mesh, which I really like. For women, I almost always offer a laparoscopic approach because of the higher likelihood of femoral hernias, even if the exam doesn’t suggest it.

I don’t routinely order ultrasounds, but if they come with one from a primary care doc or have a prior CT, it’s nice to have. Times when I wouldn’t offer laparoscopic repair would be for a really large inguinoscrotal hernia—they’re just painful laparoscopic—or if there are medical contraindications to laparoscopic surgery. My default is laparoscopic for most cases at this point.

Dr. Randy Lehman: [00:28:22] Yeah. So I have a couple of thoughts on that. Before we get too far, there’s some new data or recommendations—was it SAGES? I cannot remember. Don’t hold me to this. I saw some guidelines saying that for women, you should do laparoscopic repair. That was a new thing within the last couple of years.

Shortly after seeing that, I had a patient come in who’d had multiple vertical midline incisions for various reasons—perforation repairs and such. I quoted this new data and decided to do her repair laparoscopically, and that was a mistake. So all rules are made to be broken, and common sense trumps everything.

In my practice, if I have a man with a unilateral inguinal hernia, I do it open. If I have a recurrence after an open repair or if it’s bilateral, then I do it laparoscopic.

Dr. Randy Lehman: [00:31:03] And I definitely think those are the things you hang your hat on. Now for women, same deal—I would do it laparoscopic. Anybody I do laparoscopic surgery on, I also consent and pre-cert them for a possible contralateral repair. That way, it’s taken care of.

I agree, if it’s a scrotal hernia, I always do that open, even if it’s a recurrence after an open repair. It’s just too hard laparoscopically. But don’t forget about contraindications: prior radical prostatectomy, lower midline incisions, multiple previous pelvic surgeries. That case with the lady did not go well—it was a very difficult case.

I don’t know how much I was supposed to share—maybe I should talk to a lawyer about what all I discussed. But she’s my neighbor, and it’s my practice. I don’t think I breached duty, but there were damages. The patient ended up with a delayed bowel injury. I got the hernia fixed, but it was one of the worst things that happened.

It wasn’t necessary. If I’d just gone straight down to the hernia, which was a marble-sized defect at the external ring, I could have repaired it easily. It was clearly not femoral on the exam. I could’ve placed a small patch, in and out, and everything would’ve been fine.

Now you’ll have some stories like that. Maybe you won’t share them on a public podcast in four years, but hey, it’s about humility.

Dr. Ben Mundell: [00:31:03] No, you’re right.

Dr. Randy Lehman: [00:31:04] Those are the things you think about.

Dr. Ben Mundell: [00:31:06] Yeah, those previous pelvic surgeries—I remember getting talked into one in training during our chief clinic. We did a guy with a prior robotic prostatectomy. Those cases aren’t fun. Even if you have one of the best laparoscopic surgeons in the country next to you saying it’s the right thing to do, it’s still tough.

So yeah, I’m not doing any of those cases with multiple prior pelvic surgeries laparoscopically. Those are open for me.

Dr. Randy Lehman: [00:31:35] Yeah, great. So let’s say you’ve got a guy with an inguinal hernia on one side, and you decide to go laparoscopic because of all the reasons we just discussed. How do you position him in the operating room?

Dr. Ben Mundell: [00:32:03] Yeah, so I tuck both arms. I tell anesthesia they’ll need to give me extra room at the head of the bed and keep the drapes low. Once we’re set, he’s placed in a good amount of reverse Trendelenburg position. I make sure he’s really well strapped to the bed with a chest strap and a leg strap—both.

Dr. Randy Lehman: [00:32:30] Do you prep the scrotum?

Dr. Ben Mundell: [00:32:31] I do, yep. I prep the scrotum. I also ask that there isn’t an upper Bair Hugger blanket used. Some blankets up top are fine, but the Bair Hugger can get in your way.

Dr. Randy Lehman: [00:32:44] Okay, so where do your drapes go?

Dr. Ben Mundell: [00:32:48] We use a standard laparotomy drape. I usually have to cut it a bit to make it wide enough. I keep the whole abdomen exposed. Some people in training would just drape out the mid-abdomen or peri-umbilical region. I place blue towels in the groins and around all four sides, then place the top drape.

I think one of the key things is that it just needs to be low and, you know, out of the way of your elbows while you’re operating.

Dr. Randy Lehman: [00:33:24] Where do you put your ports? What kind of ports do you use?

Dr. Ben Mundell: [00:33:25] Yeah, so I do two 5 mm and one 10 mm port, typically. The first 5 mm is for initial entry. I make a supraumbilical curvilinear incision, cutting down to the umbilical stalk. If they’ve had no prior surgeries in that area, I lift up on the umbilical stalk. Right at the base, there’s usually a nice little soft spot where you can enter.

I go in with a "naked" 5 mm port, meaning I remove the obturator. I then use the camera to check the entry and confirm I’m intraperitoneal before insufflating. If I’m working on one side, I offset my ports slightly. The contralateral side port is placed slightly lower, and the ipsilateral port is slightly higher, centered around a comfortable hand length from the camera port.

Dr. Randy Lehman: [00:34:16] Okay, so you’re not going in optically with that 5 mm?

Dr. Ben Mundell: [00:34:19] Nope, it’s essentially a cut-down with a 5 mm port. I go in without the obturator and check the entry with the camera before insufflation. If you don’t confirm entry, the peritoneum could inflate improperly, making the surgery much harder.

Dr. Randy Lehman: [00:34:40] I see. So there’s very little risk of bowel injury because you don’t have the obturator in your port.

Dr. Ben Mundell: [00:34:45] Exactly. You still have either a Kocher clamp or a penetrating towel clamp on the umbilical stalk, holding it up while you’re pointing down toward the pelvis—but obviously not directly at the bladder or vessels.

Dr. Randy Lehman: [00:35:04] Right, but it can still be tricky if you go preperitoneal by mistake. Then you’re pointing straight toward the aortic bifurcation.

Dr. Ben Mundell: [00:35:11] Yeah, I’m not a fan of that.

Dr. Randy Lehman: [00:35:13] So where do you put the radially dilating 10 mm port for bringing in the mesh?

Dr. Ben Mundell: [00:35:20] I use one of the 5 mm ports on either side. Then I exchange the initial 5 mm port at the umbilicus for a 10 mm port. This way, I don’t need to open any additional ports. The remaining 5 mm port goes on the other side.

Dr. Randy Lehman: [00:35:36] Before I forget, do you place a stitch in the fascia at the 10 mm port site on your way out?

Dr. Ben Mundell: [00:35:40] Yes, I do.

Dr. Randy Lehman: [00:35:41] And the other ports?

Dr. Ben Mundell: [00:35:45] I don’t typically close the smaller ports. I’ve grown more comfortable using PDS sutures, but Vicryl on a CT2 needle is pretty reliable and gives good closure.

Dr. Randy Lehman: [00:35:56] Agreed. So you’ve got everything set up. You’re centered on one side, and the contralateral port is a little lower, closer to the pelvis. Just to note, I’ve gotten into trouble putting those 5 mm ports too low. They end up in the area where I want my flap, so I place them at or above the umbilicus.

Dr. Ben Mundell: [00:36:23] Yeah, exactly.

Dr. Randy Lehman: [00:36:23] I prefer a Hasson 10 mm port at the belly button.

Dr. Ben Mundell: [00:36:27] Same here.

Dr. Randy Lehman: [00:36:28] Yeah, it’s essentially the same, though I’ve tried using an 8 mm port just to experiment.

Dr. Randy Lehman: [00:36:51] And then I just couldn’t get the mesh through all the time. So I decided to forget it and make it easy for myself. Now I use the 10/12 port. But anyway, go on. You’ve reduced all the contents, and now you’ve got a nice little indirect hernia there.

Dr. Ben Mundell: [00:36:51] Yeah, so the camera is on the same side as the hernia for me. I typically use laparoscopic scissors on the contralateral port and a Maryland dissector through the 10 mm port. I mark out about 5 cm above the defect, gauging the distance using the width of the Maryland dissector when open.

Then I pull down on the median umbilical ligament and cut it with cautery. Usually, I can run my hand, kind of like cutting wrapping paper, toward the ASIS. I often have my assistant push on the ASIS to give me a landmark. Once I develop the peritoneal flap edge, I use a combination of sharp and electrocautery to get started, with good traction from the Maryland dissector.

Sometimes I switch to a soft bowel grasper to spread and open the flap further.

Dr. Randy Lehman: [00:38:07] Do you ever use that retractor with the little pad or hole in it?

Dr. Ben Mundell: [00:38:13] Yeah, sometimes. But most of the time, I just use a standard soft bowel laparoscopic grasper.

Dr. Randy Lehman: [00:38:20] How about those ones with a hole in them? I really like those.

Dr. Ben Mundell: [00:38:22] Yeah, I know what you’re talking about. They work well too. I’ll open and spread with them, especially near the transition zone of the transversalis fascia over the bladder. You’ve got to find that zone and get through it.

The most helpful thing I’ve learned is leaning on the bladder during the medial dissection. You can do a lot of blunt dissection quickly and get the tunnel down to Cooper’s ligament nicely.

Dr. Randy Lehman: [00:38:55] Some people just listen to audio, so they can’t see your moves, but yeah.

Dr. Ben Mundell: [00:39:00] Yeah, it’s that medial traction against the bladder that keeps you safe.

Dr. Randy Lehman: [00:39:06] Do you always use a Foley catheter for bilateral hernias?

Dr. Ben Mundell: [00:39:09] For bilaterals, yes. I have them void right before the case. For unilaterals, not always.

Dr. Randy Lehman: [00:39:16] Got it. What about tricks for larger hernias that are really far down?

Dr. Ben Mundell: [00:39:23] Yeah, once I’ve done the main dissection, I’ll work laterally and develop the area. Just like in umbilical hernia surgery, you get that “volcano sign” with the sac. I like to use two Maryland dissectors—one with cautery. I alternate buzzing and separating tissue, working circumferentially around the hernia sac.

It can be tedious, but it’s effective for pulling apart those little bands. Sometimes, if needed, I’ll add an extra port, though I’ve only had to do that once or twice.

Dr. Randy Lehman: [00:40:48] And probably some people I should have done open repairs for. But yeah, it gets a little tight to add an extra port for someone to help retract. Usually, I place it on the ipsilateral side, just above where my other two ports are. They use a grasper to help retract.

Dr. Randy Lehman: [00:40:48] All right, so you get the hernia sac completely reduced. Let’s say you made a hole in the sac.

Dr. Ben Mundell: [00:40:53] Yeah.

Dr. Randy Lehman: [00:40:53] How do you manage that?

Dr. Ben Mundell: [00:40:56] The biggest thing is, during training, having your attendings make you suture down there because of the weird angles. For a small hole, I use a figure-of-eight with 3-0 Vicryl. If it’s a tough angle and you really can’t get to it, there’s no shame in using a surgical clip. I use a 5 mm clip applier for small repairs. For larger holes, I’ll use a 3-0 V-Loc suture.

Dr. Randy Lehman: [00:41:29] Do you have those at your place now?

Dr. Ben Mundell: [00:41:32] We’re working on ordering them. It’s part of the process.

Dr. Randy Lehman: [00:41:36] That’s like the PDS 3-0 V-Loc, right?

Dr. Ben Mundell: [00:41:38] Yeah, exactly. The 6-inch and 9-inch lengths are both really helpful to have.

Dr. Randy Lehman: [00:41:43] Do you have a needle driver there?

Dr. Ben Mundell: [00:41:44] We do. I prefer Castroviejo-style drivers. They’re what I’m most comfortable with. There are also pistol-grip styles, which work well. The OB department has larger-handled ones, but I find those don’t close as precisely.

Dr. Randy Lehman: [00:42:06] They’re all stainless steel, right?

Dr. Ben Mundell: [00:42:16] Yeah.

Dr. Randy Lehman: [00:42:17] Okay. Moving on to the last segment—resources for the busy rural surgeon. In your two months, what are the essential resources you’re using regularly?

Dr. Ben Mundell: [00:42:22] Going back to what you said about keeping in touch with mentors from residency, that’s a huge resource. Running cases by them, like asking, "Am I crazy to do this here?" and discussing the hospital’s capabilities is invaluable. Your partners are another key resource if you have them.

I’d also plug UpToDate—it’s great to reference. If you have to negotiate it into your contract or pay for it yourself and write it off, it’s worth it.

Dr. Randy Lehman: [00:43:08] The nice thing about UpToDate is it tracks your hours and gives you CME credits. It’s simple—you’re doing the work, and it’s documented. I love it. Hey, anybody from Mayo you’ve been calling?

Dr. Ben Mundell: [00:43:22] Let me think. Not recently. Last year, we called Heller for some tough esophageal fistulas. Lately, I’ve mostly reached out to people in Phoenix.

Dr. Randy Lehman: [00:43:33] That makes sense. One more thing, Ben, and this might sound repetitive for listeners, but there’s a group called the North American Rural Surgical Society. They meet every Martin Luther King weekend in January at the Brown Palace in Denver.

It’s a one-day CME event on Saturday, about eight hours long. They also have dinners the night before and the night of, so we can build relationships.

Dr. Randy Lehman: [00:44:48] People that you just click with and can text are invaluable. Every topic at the North American Rural Surgical Society is relevant to my practice because we’re all doing the same thing, and it’s different from this.

If you go to the American College of Surgeons and listen to topics like, "We’re going to give whole blood now in our trauma protocol," it’s like, okay, we don’t even have that option. Or if they’re talking about an esophageal cancer protocol, you’re thinking, this isn’t applicable to me.

There is rural-focused content within the American College of Surgeons, and I think all rural surgeons should be part of it. But North American Rural Surgical Society? That’s for us.

Dr. Ben Mundell: [00:44:48] Yeah.

Dr. Randy Lehman: [00:44:49] You know, it’s awesome. Maybe I’ll see you there.

Dr. Ben Mundell: [00:44:51] Yeah.

Dr. Randy Lehman: [00:44:53] All right, well, thank you so much for joining us. For everyone listening, this has been the Rural American Surgery Podcast with Dr. Mundell. I’ll see you next time.

Please don’t forget to share this with all the rural surgeons in your life. Like, subscribe, and interact with us online. Thanks for being here. I appreciate you. Keep up the great work.