Episode 17
Robotic Ventral Hernia Repair with Dr. Jeremy Stoller
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, or 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, listener, to the Rural American Surgeon podcast. Today we're joined with Dr. Jeremy Stoller, and he's from Van Wert, Ohio. Thank you so much for joining us, Bud.
Dr. Jeremy Stoller: [00:00:56] It's good to be here. Thanks.
Dr. Randy Lehman: [00:00:59] So I had a great way that we met up. So I was presenting in 2020 at ACS, virtually in the middle of the pandemic about training a rural surgeon. And then I left my email at the end for people to reach out. And now over the past four years, we've really had an opportunity to kind of grow a friendship and a professional relationship as well, to be able to bounce some ideas off of each other. And I just told Bud he needed to come on and tell us a little bit more about his experience.
So, Bud, why don't you introduce yourself a little bit more in terms of your training and what your practice is like now?
Dr. Jeremy Stoller: [00:01:34] Okay. So I'm in Northwest Ohio, Van Wert, Ohio. Small community, 10,000 people, all rural. It's where I'm from. It's where I was born and raised. I went to college at Ohio State, the Ohio State University, and then I did med school at Toledo, University of Toledo, which is joined with Promedica. Now, for those people who might be listening to Toledo, south of Detroit, Michigan, about an hour. Most people don't know where it is.
And then I did med school there, and then I stayed there and did surgical residency. And then halfway through residency, I thought, you know, I kind of like... I thought I like general surgery. I just like bread and butter general surgery. And I'd always kind of kept contact with the hospital from where I'm from, like with their public relations type people. It was always kind of an option. But I wasn't always planning on, you know, going back home and it... Just exploring things, figuring out what I wanted to do. I didn't... I decided I didn't want to do any fellowships, even though there was a lot. That's what pretty much everyone was doing in my program. Not everyone, but most, you know, and then I just ended up in Van Wert, and I love it.
Dr. Randy Lehman: [00:02:52] So when did you finish residency?
Dr. Jeremy Stoller: [00:02:55] 2017.
Dr. Randy Lehman: [00:02:56] '17. And what's your practice look like now? Like, what are the biggest cases you do? What's the most common case you do?
Dr. Jeremy Stoller: [00:03:02] I, you know, I didn't have much experience or exposure to rural surgery in residency. I didn't really know what it was. But then once I got out, I started going to, like, when I went to ACS, I do all the rural surgery things and realize, oh, I'm not alone. You know, I was so surprised by the amount of endoscopy. You know, it's like 50 to 60% endoscopy. That was a huge surprise to me. And then, you know, I do hernias, gallbladders, appendix, all the acute care abdominal stuff.
Dr. Randy Lehman: [00:03:35] So are you doing your acute appies on the robot?
Dr. Jeremy Stoller: [00:03:38] Only... Only if the person's really obese or if it looks like a disaster on the inside. But mostly, I would say 90% straight stick for...
Dr. Randy Lehman: [00:03:49] How about your... All your gallbladders?
Dr. Jeremy Stoller: [00:03:51] All my gallbladders, all my hernias, even.
Dr. Randy Lehman: [00:03:54] So, if it's like a biliary dyskinesia, normal gallbladder... How... What's the skin to skin time on that for you right now after you've been doing it for so long?
Dr. Jeremy Stoller: [00:04:04] I don't know my skin to skin time, but my average console time, which they follow, is like 22 minutes, I think.
Dr. Randy Lehman: [00:04:11] Okay, so... And what... I mean, so what do you think it takes you to be docked, you know, inflated at the console and then console and then after the... You walk away from the console and go close.
Dr. Jeremy Stoller: [00:04:24] By the time I start, less than 10 minutes before I'm, you know, docked, I would say probably that's pretty good. Maybe 15. I mean, it just kind of depends on the patient.
Dr. Randy Lehman: [00:04:34] Well, great. Let's move to the first section of the show. Why is rural surgery special to you now that you've been out for seven years? Um, what have you found to be really special things about it? Obviously going back home.
Dr. Jeremy Stoller: [00:04:45] Yeah, Yeah. I just like the small hospital. I've... I've always liked the smaller, hot... Even in residency, when we would go... Of course, the one hospital we went to wasn't really small, but it was private, you know, or... And I've... I've just always liked how you know, everyone in the hospital, they know you. I mean, if you really want to, you literally can go up to the admin admin and just knock on the door of the CEO and just say hey and talk to him.
I just, I like, I always remember in residency there was this big focus on like doing medicine as a team, you know, like it was some novel concept or implement, you know, team based care in the hospital. In a small hospital, you like have to do that. It's like a necessity. If you don't know how to work in a team, you can't, you can't operate or you can't do anything. And I, I just, I like that, that small, intimate feel of the, of the, of the rural hospital is what really, I think gets to me.
Dr. Randy Lehman: [00:05:53] Yeah, I love it. It's just like the town, basically. Yeah.
Dr. Jeremy Stoller: [00:05:55] Yeah.
Dr. Randy Lehman: [00:05:56] Let's roll into how I do it. So I want to talk about ventral hernia for a while because there's so much nuance to it. People don't want to maybe talk about ventral hernia so much because of that, because there's, there's no, there's a lot of times not a right or wrong way to do it. Matter of fact, they've changed the codes about two years ago and the codes now no longer laparoscopic or open. It's just repair of anterior abdominal wall hernia.
I would, I think that's a good move to reflect the fact that there's a lot of surgeon discretion, but also on the other side of the discretion, not a right or wrong. Like you could have 10 surgeons, 20 opinions about how to fix that hernia.
Dr. Jeremy Stoller: [00:06:39] Well, that's probably because we just don't know, you know.
Dr. Randy Lehman: [00:06:43] Yeah, there's some maybe lacking data, but it's... Yeah, sure. So tell us, which ventral hernia do you want to start with? Which you know, patient, mock up patient or whatever.
Dr. Jeremy Stoller: [00:06:54] I mean, of course in my practice it'd be like, you know, the person who's on the verge of needing bariatric surgery. And so there's always that like conundrum, you know, and, and would have like a, you know, 1 to 4 centimeter defect, whether it's an incisional defect or primary umbilical or epigastric.
Dr. Randy Lehman: [00:07:19] So maybe before you say that, are there criteria that you tell the patient? No way. Like BMI criteria, any comorbidities, anything like that?
Dr. Jeremy Stoller: [00:07:31] You know, in Vanworth, like nobody's gonna stop smoking. I mean, it's just not gonna happen. And maybe I'm a little too cynical in that regard. I... I'll talk to the patient about it, but honestly, I've operated on so many people that smoke, and they do totally fine for... For ventral. For a straightforward, you know, robotic slash ventral hernia with three small, tiny incisions. It's like, whatever, you know.
But I do talk to them about smoking cessation, but it depends, you know. I definitely won't touch someone above BMI 50. That's for sure. BMI 40, I have that conversation with them. That's the number I found people... A lot of people still use. Although I was, like, kind of humored this year. AC... There was a panel session on ventral hernias in the obese patient, and I was kind of like, you know, tickled that like the, the experts up there finally were admitting that, like, it's really hard to get patients to lose weight. So what do we do about this?
Dr. Randy Lehman: [00:08:36] Yeah. Yeah.
Dr. Jeremy Stoller: [00:08:37] Because so many of my patients are just like, "I'm not losing weight," you know, like, they're just not going to do it. It's like 40 to 45. I mean, I get really above that. I... I start to get kind of a little like, you know, I don't... I don't know if I want to do this unless if the person's, like, incredibly symptomatic, you know. I talk to them about the risks, have a conversation, you know, and then sometimes I'll do it, you know.
Dr. Randy Lehman: [00:09:05] Well, what I saw in residency was, you know, strict tertiary quaternary referral center, where we ended up using more of BMI cutoff 35.
Dr. Jeremy Stoller: [00:09:21] I've seen that number. Yeah.
Dr. Randy Lehman: [00:09:22] And... And then we, you know, we would make them quit smoking, improve it with a urine cotinine level, and just have no qualms about just not fixing it. I would say that was... But then it's a big system, and there's... There's variation in practice. I'm in critical access setting, and I... I feel like I have...
Now, I had a patient this year that did cry when I told her she needed bariatric surgery and I wasn't going to take her to the OR.
Dr. Jeremy Stoller: [00:09:48] Yeah.
Dr. Randy Lehman: [00:09:49] But normally the people receive the conversation really well about weight, and I kind of have a delivery that I think works. And so because your bariatric referral numbers are 35 with comorbidities or 40, then I just say, look, you meet criteria, you'd actually be an excellent candidate for bariatric surgery because you're... You're heavy, but you're not, like, you know, too...
Dr. Jeremy Stoller: [00:10:14] Right.
Dr. Randy Lehman: [00:10:14] Far gone. And this would change your life. And if I could wave a magic wand, you know, this is what I would... I would fix is your weight rather than your hernia first. And this is why the recurrence rate... So anyway, I have this way that I kind of phrase it and... But again, that's... This is why we're talking about it because there is not a right or wrong. And... And I definitely have broken my own rule with very symptomatic patients because, you know, I'm worried that they're going to strangulate before we get right.
Dr. Jeremy Stoller: [00:10:42] Or they say they can't exercise because it hurts too much or, you know. But yeah, I had the conversation too there number of times where, you know, they'll... They'll be like, yeah, okay, I've referred to bariatric surgery. Or they'll be... I need to figure out about maybe trying to work the GLP-1 inhibitors into the whole conversation now. But... But again, with insurance and cost, a lot of my patients I highly doubt would be able to afford... Afford them.
Dr. Randy Lehman: [00:11:11] The way I get around that is there's two medical weight loss clinics, and so I just refer them to that. We're gonna make a referral one way or another. Medical weight loss, surgical weight loss, and we pick. Or a lot of times I just go surgical weight loss. They still talk to them about it, and then I... Or refer them back to their primaries, which... The primaries a lot of times appreciate that. And if they're diabetic, then they'll get it covered, but if not, then they're gonna have to decide something else. But, yeah, but...
Dr. Jeremy Stoller: [00:11:37] Yeah, that's tough. I mean, so...
Dr. Randy Lehman: [00:11:40] So tell me about the... You... You said the 1-4cm, say primary umbilical hernia. Okay, that's fine. Before we talk about that, what about the 8-millimeter primary umbilical hernia? So how do you fix that if...
Dr. Jeremy Stoller: [00:11:54] You know, if the person's not... if they're... Of course, I don't have a BMI cutoff, but if they're smaller, I'll do open umbilical hernia or suture herniorrhaphy. You know what? Suture PDS. Oh, PDS. I'll do you...
Dr. Randy Lehman: [00:12:12] You just stitch it straight together. Do you do any... is it simple interrupted sutures or...
Dr. Jeremy Stoller: [00:12:18] I'll do figure-of-eights. Like small bites usually.
Dr. Randy Lehman: [00:12:22] So I was at Mayo and I... I was an intern. Of course, I'm like reading Schwartz's, getting up at 4:30, reading Schwartz's before I go in and stuff. And I just remember going in, we had umbilical hernia. I'm like, I'm going to be owning this case, little one. And I'm presenting it. I'm like, I think we should do the Mayo vest-over-pants repair and the... I remember the chief of department of surgery: "We haven't done vest-over-pants repair in 50 years." You know, like the things that you don't forget.
But yeah, I just, you know, free to get rid of the sac and free up the edges. Maybe clean it up a little bit and stitch it up just like you're talking about. If it's that small, it's usually like two interrupted stitch. I mean, sure. Okay. And I got one more question about that, though.
Dr. Jeremy Stoller: [00:13:14] Yeah.
Dr. Randy Lehman: [00:13:14] You ever done one of those under local in your office?
Dr. Jeremy Stoller: [00:13:17] Not in my office, but I have done them under MAC and local in the OR. And it's not... I mean, it's... it's not... not hard. I did, I have... I had one of the older surge... Like my staff, an old staff member when I first came, she talked about how the surgeon who was there in the '90s would do that.
Dr. Randy Lehman: [00:13:38] Yeah. So I had a primary care ask me that, and I was like, I never heard of that. You know, I... I don't think so. But then a few months after that, I had this patient who's known to me. I'd done like two, three surgeries on him before already. He was referred for a lipoma of the abdominal wall. It was off midline. It's like in left upper quadrant. And I did... We did an ultrasound. It was this firm, rubbery mass. Would say probably 5cm in size. The ultrasound said lipoma. And so... But it was pretty good size.
And so I actually took him to the operating room and I did it in the OR, but on a day when... Because this is in a critical access setting where we don't have anesthesia all the time.
Dr. Jeremy Stoller: [00:14:23] Yeah.
Dr. Randy Lehman: [00:14:23] So I just did it on one of my local days.
Dr. Jeremy Stoller: [00:14:25] Yeah.
Dr. Randy Lehman: [00:14:26] And so he's... he's wide awake. And I'm doing it in the OR. Lipoma resection. And I'm chasing it down to find maybe a feeding vessel or whatever. And all of a sudden I'm like, this isn't ending, you know, and it just funneled down to a tiny, probably 2-centimeter discrete hernia defect.
Dr. Jeremy Stoller: [00:14:46] Yeah.
Dr. Randy Lehman: [00:14:46] I'm like, "Hey, this is a hernia. What are we going to do?" And he's like, "Oh, I don't know. What do you, what do you normally do?" And I'm like, "Well, normally I fix this with mesh and I think that's what we should do. But you know, you're under local. Normally I would have you asleep." There was, there's no option. So I ended up just using a lot of local and I did a full out hernia repair using a VentralX™ ST mesh and tiny one or something. I think I might have used the medium one. It was, it was either the small or the medium. But yeah, you know, four point stitch parachute, dropped it in close defect over the top and he did fine.
So then after that case I'm like, this was actually bigger than just a fingertip belly button. I definitely could do a fingertip belly button in the right patient in the clinic under local. But I have never actually done that myself. You know, it just thought I'd ask.
Dr. Jeremy Stoller: [00:15:49] Yeah, I, and I've seen debate actually. I, I really follow the hernia closely because it interests me for a while. The, the, I really am appreciative to the IHC, the International Hernia Collaboration, the Facebook group, seeing the discussions there, you know, but there's, you know, it's like...
Dr. Randy Lehman: [00:16:08] Well, is it, there's a lot of robot bias on that. But... yes.
Dr. Jeremy Stoller: [00:16:11] Is it less than 2 centimeters or, you know, or can you go up to 2 centimeters for the suture herniorrhaphy or is it really just 1cm? You... I would say... I... Again, most of my patients are bigger and as they get bigger, even if it's smaller, I mean, if it's 8 millimeters really small. Okay, sure. But I mean, I just, I don't like doing a suture herniorrhaphy in someone with a BMI of like 35.
Dr. Randy Lehman: [00:16:44] Right.
Dr. Jeremy Stoller: [00:16:45] You know, and so I'm just like, I'm gonna do a mesh repair on you. Like, I don't, it's just again, no data whatsoever. But it just to me...
Dr. Randy Lehman: [00:16:54] But you're going to put in three 8-millimeter ports that you're not going to close.
Dr. Jeremy Stoller: [00:17:02] Yeah.
Dr. Randy Lehman: [00:17:02] Right.
Dr. Jeremy Stoller: [00:17:03] Yes.
Dr. Randy Lehman: [00:17:03] And you're going to fix the 8-millimeter...
Dr. Jeremy Stoller: [00:17:05] I'm going to, I'm going to, I'm going to play, play the odds that they're not going to get a port site hernia. You know, I mean nobody knows, nobody knows what the rate of port site hernias are, especially with the robot with the 8. It happens, but I don't, as far as I know, nothing has been... I, I'm not sure. Yeah, it means low, it sounds like.
Dr. Randy Lehman: [00:17:22] But just devil's advocate, I'm not saying you're doing the wrong thing. I, I mean...
Dr. Jeremy Stoller: [00:17:27] Well, trust me, I'm aware. I'm aware of... of...
Dr. Randy Lehman: [00:17:30] Yeah. So, okay, let's carry on to the routine guy that comes in. We...
Dr. Jeremy Stoller: [00:17:36] He...
Dr. Randy Lehman: [00:17:36] He's got a BMI of 33, so we all agree. And he quit smoking or whatever. So you got him optimized and everybody agrees he should fix it, make it easy for people so they don't Monday morning quarterback us when the recurrence happens. But you've got... It's... It's 3cm in size, you know, especially with the new coding guidelines. It's 3.0. And what are you going to do?
Dr. Jeremy Stoller: [00:18:02] So, yeah, you know, are we going straight to the surgery now at this point?
Dr. Randy Lehman: [00:18:06] I think so. So you're going to put them in the OR, general anesthesia, arms tucked.
Dr. Jeremy Stoller: [00:18:12] Yes, arms are tucked. Sometimes the right arm stays out. But I have, I have jumped all in with the robot. So this is all robot. I should mention we have all CRNAs at the hospital, thankfully. Coverage 24/7. And they're all fantastic. Like I would let them all do my anesthesia, sure.
So, you know, put them to sleep. Tuck the left arm, usually tuck both arms. Prep and drape. I do Veress needle entry at Palmer's Point exclusively, unless if there's something that's... But... But yeah, in general, if this straightforward hernia, Veress needle entry, you know, Palmer's Point. One or two finger breadths below midclavicular line, below the subcostal margin on the left side. Saline test. Get it in. I hate the Veress needle, but it is what it is.
Dr. Randy Lehman: [00:19:20] I don't know if I've talked about this on the podcast. Perhaps there's a listener who's a resident or whatever, medical student, so... So Veress needle is a retractable needle that you can use for entry. And when he's talking about saline test, what you're doing is you're fine... You can look up Palmer's Point - a picture's worth a thousand words. But yeah, mid clavicular line, 2 cm below or two finger breadths below the rib cage in the left upper quadrant. Now, are you making a small nick with an 11 blade?
Dr. Jeremy Stoller: [00:19:47] I am, yeah. Small.
Dr. Randy Lehman: [00:19:50] Then you're just feeling through the layers with this Veress needle and then it pops through your muscle layer. So describe what you're feeling there.
Dr. Jeremy Stoller: [00:19:56] Technically you're supposed to feel three pops, but as I've done it more and more and more, sometimes it's one big pop, sometimes it's two pops. And it, as you do it more, I felt like you just kind of get a sense of when you're through. But when you're first starting out, it's so confusing.
Dr. Randy Lehman: [00:20:17] So the reason he's feeling three pops is because you're medial to the semilunar line and so you're feeling anterior and posterior fascia and peritoneum. Those are the three pops.
Dr. Jeremy Stoller: [00:20:27] Yes.
Dr. Randy Lehman: [00:20:27] And then the needle will self-retract then and become sort of blunt.
Dr. Jeremy Stoller: [00:20:32] Yeah.
Dr. Randy Lehman: [00:20:32] And then you're just holding it. You know, your wrist is bracing so you're not plunging and you're just going with your fingers in your hand basically to push it through. And then use a little bit of saline on top of the open needle. And if you see it drop into the abdomen, then you feel real comfortable hooking the gas up. And you do your insufflation now? Yeah, when we're insufflating again, this is for the trainee, but you know, typical abdominal insufflation is 15 millimeters of... of mercury of pressure. Am I saying that? It's not centimeters of water. Millimeters of mercury pressure.
Dr. Jeremy Stoller: [00:21:11] Mercury, yeah.
Dr. Randy Lehman: [00:21:13] And flow, high flow would be like 40 liters a minute. Yes, would be like high flow. Low flow would be three liters a minute. So these are settings on your insufflation machine. But if you hook up high flow to a Veress needle, you will never get more than 3 liters a minute anyway, because of Pascal's law, I believe is going to be your resistance against your circuit. So just something to be aware of.
Now, while we're on this very boring topic of physics, let me ask you if you're doing another type of entry besides Veress needle. Do you go straight? Do you ever like slowly insufflate for a little bit for any reason to see how it goes with anesthesia? Or like for me, where I'm going with this is I put a Hassan almost always and cut down technique Hassan, which is a 10-12 port, you know, that I put in bluntly and then I just go straight to 40 every single time. And it's like a discussion with the staff. Like for some reason I can't get them to always do this. Is there any drawback to that? Like they're going to get hemodynamically unstable or something?
Dr. Jeremy Stoller: [00:22:26] I do the same thing. I go straight, high flow, you know. Yeah, but... And I had had the number of times where, you know, the patient brady... So you okay. And you turn off the gas. And I had a patient last year where we insufflated and I was a little tricky because like I... She had a huge left lobe of the liver. My Veress needle went in the left lobe liver, of course, but she, I, I think ultimately what she was young, healthy. What ultimately happened was she just had this vigorous vagal response and just coded. I mean, it was terrifying. And ever, ever since that if anesthesia says bradycardia, I, I pop, I pop the... on the cannula.
Dr. Randy Lehman: [00:23:19] I just release the insufflation right away. Yeah.
Dr. Jeremy Stoller: [00:23:21] I pop it and immediately just desufflate the abdomen. Like I had an attending who would used to do that. And I always thought it was kind of weird. Now I understand.
Dr. Randy Lehman: [00:23:30] Yeah. There's the power of experience.
Dr. Jeremy Stoller: [00:23:33] Okay. Yeah.
Dr. Randy Lehman: [00:23:35] All right, Dr. Lehman, get back on track here. Your listener is fading fast.
Dr. Jeremy Stoller: [00:23:40] So pneumoperitoneum. I put in three VisiPort, three 8-millimeter robotic ports on the left lateral abdomen. You know, direct visualization. Dock the robot go into the...
Dr. Randy Lehman: [00:23:56] Take your shoes off.
Dr. Jeremy Stoller: [00:23:56] Take my shoes off?
Dr. Randy Lehman: [00:23:58] Yeah.
Dr. Jeremy Stoller: [00:23:59] I'm telling you, the robot, it's amazing. I will never go back to ski sticks. I'm telling you, it's amazing. So, all right, that's fine.
Dr. Randy Lehman: [00:24:13] I'd probably be there eventually, but I don't. I'm in four hospitals, and so my situation, I don't have a robot. I trained. I was certified when I left residency, but I haven't been using it for five years. So yeah, and it's going all right. But yeah, this is the beautiful part about it. So carry on.
Dr. Jeremy Stoller: [00:24:28] Yeah. So then I reduce whatever's incarcerated. Reduce it, and then I strip the peritoneum. There's always a... I don't think there's any data to this, and I noticed people started doing this or advocating for it maybe within the last 10 years or so. I think it makes sense, you know, that's like, what – you don't put a mesh up against fat. You want that mesh to touch the fascia.
There's always this middle strip of peritoneum that you see, and I take it down. Depending on the size of the defect, and if I think I can, that's when I'll do like what's called the RTAP, you know, the pre-peritoneal repair. I don't lose a lot of sleep if I can't do it, because forming that pocket in the umbilicus and epigastrium, making it big enough to fit like a 10, 11, 12 centimeter mesh in can be really hard. I used to lose a lot of sleep over it, and I'm just like, whatever, you know.
So I take down that midline strip of peritoneum, but I don't... I just make a pocket, and so it's just hanging there. And then I close the defect. After I take that down, I close a defect with a barbed suture, like a V-Loc. Generally, if it's bigger, I'll use a Stratafix. Once it starts to get big, even up to 7 centimeters, you know, if I'm doing like an IPOM and...
Dr. Randy Lehman: [00:26:11] Usually close that vertically or transversely or just however it looks, I don't close.
Dr. Jeremy Stoller: [00:26:15] It cephalad to caudad. Transverse I would call that transversely is what I would call that.
Dr. Randy Lehman: [00:26:20] Right, right.
Dr. Jeremy Stoller: [00:26:21] Sometimes I do. If it seems like it's... if it's like a weirdly shaped hernia, I will close it transversely. But generally I'm closing it from the patient's right to left. Like, you know, you're closing the midline. Does that make sense?
Dr. Randy Lehman: [00:26:35] Yeah. Yes.
Dr. Jeremy Stoller: [00:26:36] Yeah. So that's like the IPOM plus, you know, what they talked about within the last, I don't know, five, 10 years, probably closing the defect, actually. So I do that and then I'll put in the mesh. Gosh. What do you... If it's like 1 to 3 centimeters, I'll probably do like a 10 to 12 centimeter mesh. Once it starts to get beyond that, I'll do more like 12 to 15 or bigger, you know, as it gets bigger.
Dr. Randy Lehman: [00:27:18] Yeah, so it's 3.0 for this guy. So you did 10 centimeter?
Dr. Jeremy Stoller: [00:27:22] Yeah, 10 to 12 centimeter mesh.
Dr. Randy Lehman: [00:27:24] Okay. Can you cut it like an oval or how do you...
Dr. Jeremy Stoller: [00:27:27] Well, if it's... If I can get the pocket, then I'm doing an RTAP and I use a medium weight polypropylene mesh uncoated, and I put a little stitch right in the center to mark the midline or to mark the very center of it. And I save my barbed suture. I don't cut it at that point. And I work kind of... and I go back myself right to about the center of the defect.
Then I'll put that barbed suture right through the center of the mesh to kind of make sure I'm centered. And then I use a barbed suture, a 3.0-barbed suture on the right lateral aspect. And I run it laterally like so. This will be under the rectus sheath parallel to the midline.
Dr. Randy Lehman: [00:28:14] Meshes down, and you're stitching.
Dr. Jeremy Stoller: [00:28:17] Meshes up the back.
Dr. Randy Lehman: [00:28:18] It meshes up. Okay. Because I'm saying I'm imagining it down and you're stitching the back layer and then folding it up. But no meshes my center stitch. Okay, gotcha.
Dr. Jeremy Stoller: [00:28:29] And then I do the barbed suture laterally along the right lateral rectus muscle. It'll cover, like, the central portion, because I just... I don't know, I just don't like just ripping that out and removing it. So it's a little tedious. It adds time, but, I don't know, makes me feel better, I guess. And then the mesh is secured elsewhere, just as opposed to not just the periphery, because I don't like it. With the intraperitoneal underlay mesh, when you secure the perimeter... and it's just... it doesn't feel like it's touching anywhere else, you know. So I like having...
Dr. Randy Lehman: [00:29:02] Maybe a setup for a seroma. Now, you did anchor it in the center.
Dr. Jeremy Stoller: [00:29:06] I guess I did, yeah. But sometimes I don't. I'll remove that stitch after I get it secured peripherally.
Dr. Randy Lehman: [00:29:13] So you start about 5-6 cm lateral to the midline for making your peritoneal defect in with your 10 to 12 centimeter mesh. And then take, if you can take it 5 to 6 centimeters to the other side of midline. And that all falls.
Dr. Jeremy Stoller: [00:29:27] That all falls down, yeah.
Dr. Randy Lehman: [00:29:29] How big does a defect have to be? Or what other things would push you to do something beyond this approach we just described?
Dr. Jeremy Stoller: [00:29:36] So somewhere around... Some people go up to 8 centimeters in terms of the IPOM, and I've done like 7 centimeter defects. I think I've done 8 centimeter defects, and it totally comes together. Now I'm using a much bigger mesh.
Dr. Randy Lehman: [00:29:54] So once it's 10, now what are you doing?
Dr. Jeremy Stoller: [00:29:57] Then I'll look at doing a... A RIFS TAPP, or if... If I can, maybe an eTEP. I... You know, I've done a handful of TAR, but I... I don't know. I'm thinking... I'm not gonna bother with that. I just don't do enough. And I'm... I'm just like, they need to go somewhere else. It's not... Not in my hands. You know what I mean? But, yeah, then. Then I'll consider a RIVES-STOPPA, and I'll. And I'll do that robotically, too.
Dr. Randy Lehman: [00:30:30] So how are you accessing the... When you do that?
Dr. Jeremy Stoller: [00:30:34] If the only RIVES-STOPPAs I've done robotically have all been what's called eTEP. And, and what that is is that you, you, you use an ultrasound to mark out the... After the patient's asleep, prepped and draped to mark out the, the anatomy of the rectus muscles. And you go in, it's usually left upper quadrant. The first one is on the very lateral edge of the rectus muscle. And it's a VisiPort. And you just watch and you get into the posterior rectus space and then you insufflate.
Use the camera then to kind of open up that retro rectus space. And then once that space is opened up, place your two other ports into that retroactive space. Now you have to have like a wider rectus sheath. I think it's like you need more than an 8 centimeter wide sheath. If the sheath's really narrow, I mean, it's like there's no space, you know, so you need a nice wide rectus muscle to do this.
And they have that formula where it's like the rectus muscles. The, the width of the rectus muscle needs to be twice the length of the defect or something like that. If I remember right, I always have to look it up because I always forget. And so then, and then you, you release the medial edge of the rectus muscle. Once you've cleared out that left retrorectus space minimal invasively, you release the medial edge and then you're getting into the pre peritoneal space and then from there you reduce the hernia.
The important part of this is that on the CT scan, you really don't want to see the bowel plastered up against the posterior rectus space because you worry about injuring bowel and stuff like that. And you really need to keep the hernia sac that has to be the posterior wall or like the posterior layer, because with retrorectus. I remember when I was in residency, I was so confused and even learning it when people were first talking about this approach, like, you don't. When you're doing this approach robotically, at least for me, and as I talk to my friends who do it, you're not approximating the posterior rectus sheaths together like the layer.
You're completely releasing the posterior rectus sheaths. And then it's the peritoneum and the hernia sac that form the bridging posterior layer to then the other posterior rectus sheath that you release. Does that make sense?
Dr. Randy Lehman: [00:33:23] Yeah, it does.
Dr. Jeremy Stoller: [00:33:24] It took me... Yeah. And that's. And then as you. And you close any holes in the peritoneal layer. There's any holes in the hernia sac. And then that's just your posterior layer. That's the release. And then. And then I'm releasing the other. The right posterior rectus sheath, getting into that space and then putting in a nice size mesh based upon uncoated mesh. Oh, sorry. And then closing the defect with barb suture. And then putting in the mesh. Then after that point. And I don't leave drains. If it's just a straightforward, minimally invasive.
Dr. Randy Lehman: [00:34:03] And you're bringing in a uncoated polypropylene big mesh and you're stitching it in the center.
Dr. Jeremy Stoller: [00:34:12] No, it's just. It's just filling up the entire pocket that you make.
Dr. Randy Lehman: [00:34:19] And how do you do. Do you put any stitches?
Dr. Jeremy Stoller: [00:34:22] No, not, not. Not if it's a minimally invasive, like, totally extra peritoneal eTEP.
Dr. Randy Lehman: [00:34:31] Yeah. Have you had seroma problems with that?
Dr. Jeremy Stoller: [00:34:35] You know, once or twice, but I never drained it. Patients did fine, like. And I think it was all incidental.
Dr. Randy Lehman: [00:34:44] Yeah, yeah, that's a great case. And then you're talking about, you know, open RIVES-STOPPA with a TAR or. Or robotic with a TAR, you know, being something that you would currently send out.
Dr. Jeremy Stoller: [00:34:58] For the most part, I've done it. I start, I was like, oh, I'm going to do this, but I just don't see enough. And my patients did okay, thankfully. But, like, it's long, it's complex. I don't want to mess the patient up. I mean, they talk about those disaster complications, you know?
Dr. Randy Lehman: [00:35:16] Yeah. Do no harm. Got it.
Dr. Jeremy Stoller: [00:35:17] Yeah.
Dr. Randy Lehman: [00:35:18] Well, this is great. I think we should move on just because the sake of time. But we could talk. I'm sure we could talk all day. This is a great intro, primer, and then some of that stuff. If you are a resident, you're going to have to be doing some more videos, but luckily, robotic area. Excellent videos. So you can watch all this. All right, so that was the how I do it. We can move on to the financial corner. Do you have a particular money tip to share with our listener?
Dr. Jeremy Stoller: [00:35:44] Yes, I do. So I'm your typical doctor. I know nothing about finances. But my dad is an accountant, ran a practice forever. My brother took it. You know, he kind of bought my dad out from that practice. It's a private firm. My other brother's a financial advisor. So I surround myself with people who know what they're talking about, and I put an enormous amount of trust in them. And my wife manages the finances of our house.
But my dad, through years, decades and decades of being a CPA, he had these rules and his one rule was don't let more go out than what comes in. And that's the driving rule. I mean, yeah. And I graduated residency, we just paid off our debt, just that was number one priority. Getting the debt paid, getting the mortgage paid on the house, you know, being I guess frugal in that regard, like so I'm a big believer in that and just being careful with how you spend your money. That's about it though. Sorry, I'm not.
Dr. Randy Lehman: [00:37:06] It's good. The expectations versus reality. I heard recently that happiness is the difference between expectations and reality. Or something like that.
Dr. Jeremy Stoller: [00:37:16] Yeah.
Dr. Randy Lehman: [00:37:16] And there's another quote that what you said made me think of, financially wise. It's a, I believe, Charles Dickens character: "Annual income £20, annual expenditure £19, 19 shillings and 6 pence. Result: happiness. Annual income £20, annual expenditure £20 and 6 pence. Result: misery."
Dr. Jeremy Stoller: [00:37:41] Yes, yes.
Dr. Randy Lehman: [00:37:42] Just a little margin which, I mean I'm a big fan of a bigger margin than that, but yeah, yeah, yeah, that's great. More coming in than going out. Did you have a classic rural surgery story to share with the listener?
Dr. Jeremy Stoller: [00:37:59] You know, I, I, I, I like this one. So I live on like the main drag that goes through Van Wert. It's a two-way, it's Highway 127 and it connects two big interstates in Ohio or like four-lane highways, you know, and the truck traffic is ridiculous. I mean hundreds and hundreds of truck traffic, you know, throughout the day.
And I had a patient that I saw and he's a truck driver and he, I was following him for a wound. It's a long story, won't get into it. And he came into my office one day and he said, "You know what, I was having a really tough day, just, just down in the dumps. And I drove by your house and your kids were out in the front and they were doing the, they were doing this." You know what this is.
Dr. Randy Lehman: [00:38:58] All right. Yeah, honk, honk for me, honk for...
Dr. Jeremy Stoller: [00:39:01] Me that you know, where you're pumping your arm. Because I like teaching my kids how to do that. And he's like, "And I saw your kids pumping their arms and I honked my horn and it made my day."
Dr. Randy Lehman: [00:39:12] Oh man.
Dr. Jeremy Stoller: [00:39:13] And I just, I was just like, wow. And he was like, "Not many kids do that these days." And he's like, "Thank you for doing that. That was great. That made my day." The last story is: My second operation when I first started, brand new attending strangulated hernia textbook, you know, it's like, oh yeah, I can do this. You know, like fresh out of residency, you know, walk in the room. It's the, the mother-in-law of my dad's longtime fellow CPA.
Dr. Randy Lehman: [00:39:47] Her.
Dr. Jeremy Stoller: [00:39:49] So there's that connection. You know, I like grew up knowing I didn't know the patient, but it was the patient's mother-in-law.
Dr. Randy Lehman: [00:39:56] Yeah.
Dr. Jeremy Stoller: [00:39:56] But then it was the grandmother... grandmother-in-law of my, one of my best friend's fiancée's. So one of my best friends, he's married to this, he's getting engaged, this girl, it's her grandma, you know. And yeah, and so then I, I do the operation, she does well of course. Then it's like as I'm doing the operation, my mom comes over to the house and she's like, "I hear that Bud's operating on so-and-so" to my wife. And I was like, I don't know, you know. And then the day my brother who works with, you know, the daughter of the patient, he texts me, "Hey, I heard you operated on so-and-so," you know, and of course I'm like, I don't know what to do because I, you know, it's like you can't talk about patients and...
Dr. Randy Lehman: [00:40:43] Right.
Dr. Jeremy Stoller: [00:40:43] That, that was, that was an experience, a learning experience for me. Like how do I maintain patient privacy? But like everybody knows I operate on the patient anyway, you know, so.
Dr. Randy Lehman: [00:40:54] Yeah, but people really like it when you, when you use discretion.
Dr. Jeremy Stoller: [00:40:58] Yeah.
Dr. Randy Lehman: [00:40:58] And then people love it when my, when they ask my wife about surgery that I've done on somebody everybody knows and she has no idea sometimes, you know, because let it go. And they love that because then they know, you know, hey, yeah, I know everybody in my community is going to know I had XYZ surgery. But it's not that. My surgeon who I trusted to like enter my body, you know, and put me to sleep and you know, do surgery on me while I'm asleep and I'm very vulnerable in that scenario. He's not the one that's talking about it. So. Yeah, that's that. Those are some classic rural surgery stories. I love it. Lastly, I know you're involved in ACS, but did you have a resource for the busy rural surgeon before the busy rural surgeon gets to his day?
Dr. Jeremy Stoller: [00:41:47] Yeah, I, I, the social media forums, they, they have their, their place, you know, they have their limitations, but they're like a life source for me, you know, International Hernia Collaboration, International Robotic, you know, and then there's another app called Surgeon, which is a... That's its own app and its own social media platform. That. And then General Surgery News. Amazing love General Surgery News.
Dr. Randy Lehman: [00:42:19] I've seen. I've seen your articles. Yes, very good, Professor Stoller.
Dr. Jeremy Stoller: [00:42:25] And then. And then that's it. And then the ACS forums did a great job this year for the rural surgeon. I mean, fantastic panel sessions. And. And for the rural surgeon. And we've had a running text thread since we graduated, discuss cases, get their thoughts. And then. And then other of my residency friends that are still in solo practice [Uncertain: "Solito"], you know, it's nice. You just text them, send them the CT, you know. Yeah.
Dr. Randy Lehman: [00:42:59] It's fun to keep up. And then it's also part of your adjunct for your practice. Yeah. I don't know how it worked out, but we talk about cases all the time, especially big skin cancers. And if you come back, that's what I want to talk about next.
Dr. Jeremy Stoller: [00:43:12] Awesome.
Dr. Randy Lehman: [00:43:13] So, hey, thank you so much for joining us on the Rural American Surgeon. This has been our show with Dr. Stoller. We will catch you next time. Thanks for being our listener. Thank you.
