Episode 2

Trailblazing Rural Surgery with Dr. Tyler Hughes

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. Dr. Hughes, thank you for joining me on the Rural American Surgery podcast. It is a true honor.

Dr. Tyler Hughes: [00:00:52] Well, it's a pleasure for me to join you and look forward to our conversation.

Dr. Randy Lehman: [00:00:59] We're going to start with an introduction you might need no introduction for most people. Dr. Hughes has done a lot of things. One, the first way that I know about you is I saw something online about the first Rural Surgeon of the year. Am I correct in saying that?

Dr. Tyler Hughes: [00:01:18] I think you're referring to the National Rural Health Care Association.

Dr. Randy Lehman: [00:01:25] Yeah.

Dr. Tyler Hughes: [00:01:26] And I was Rural Practitioner of the Year in 2012.

Dr. Randy Lehman: [00:01:30] Right. So that just kind of epitomizes it, but very active in the American College of Surgeons. You were instrumental in starting the Advisory Council on Rural Surgeons within the American College of Surgeons, served as the first chair, and then you're involved with the Board of Regents. Tell us about the rest of your career with American College of Surgeons. And then I've heard that you're recently taking on a role with medical school at KU. Can you please tell me a little bit about that and where you're going in the future?

Dr. Tyler Hughes: [00:02:02] Sure. Well, let's see. As to the college, I served, as you said, as the first advisory chair for the Rural Surgery Council. That was a six-year term. I was concurrently on the American Board of Surgery as a director at that time. I finished that up in 2019. I thought I was pretty much done in leadership. And then I was appointed Secretary of the College, which was a three-year term.

And again, I thought I was done with the college, and I was surprised to be elected first vice president. And this is my vice presidential year. I've never been an actual regent, but I've been in the regent's room now for, gosh, several years. So I've had the honor of being sort of a fly on the wall with the regents. And then, of course, the other thing I've done is run the ACS Communities, which is a social media platform, which really started out as an effort on the part of Phil Carapresso and I to relieve some of the professional isolation that rural surgeons feel. Right.

Dr. Randy Lehman: [00:03:22] And all of this is coming on the back end of an actual practice in rural surgery in McPherson, Kansas. And you can tell me a little bit about your background in that practice.

Dr. Tyler Hughes: [00:03:33] Sure. I started practice in 1983, and I was a classic urban surgeon for 12 years, running a sixth surgeon practice. We practiced at five different hospitals. In 1995, I moved to McPherson, Kansas, and practiced there for like, 21 years. I was on call every other night most of that time. Had one year where it was one in three call. It was a great practice. I learned tremendous about myself and about surgery. The funny thing is, when I moved away from Dallas, everybody said my career was over and I'd never be heard from again. But it just goes to show you, being in a small place doesn't mean that you have to be a small surgeon.

Dr. Randy Lehman: [00:04:28] That was the springboard into a lot of other things. Well, that's a great introduction. And then tell me about the school and where you're going, where you see yourself going with your work in the future.

Dr. Tyler Hughes: [00:04:38] So in 2016, I felt it was time for me to step back from the operating room. The average age of retirement, actually, of a surgeon is about 63, which surprised me when I looked that up. But I felt that I wasn't through contributing, so I felt teaching would be a good idea.

I looked around, had three or four offers, but the University of Kansas School of Medicine at Salina, Kansas, offered me a job. And, you know, I thought it was a real job. And it turned out they just wanted me around. I never figured that out. So I just worked like crazy. And we did a lot of things with point of care ultrasound simulation, enrichment weeks, the honors program, the academic curriculum, which is now called ACE.

And so I did that for about six, seven years. We had a turnover at the dean's position, and I was asked to serve as dean, and I agreed to do that for two or three years, about 18 months into it now. It's a different life than being a rural surgeon, I can tell you that. But it's interesting that it's sort of like a second career. We'll see how it turns out. There's an end to all things, and I look forward to someday just laying on beaches somewhere rather than working full time.

Dr. Randy Lehman: [00:06:14] That's right. And there's a special way that I got to know you because I was just a medical student. I finished Medical School in 2015 and discovering the whole field of rural surgery, knowing that I wanted to come back to the town that I grew up in, where I just had the opportunity last summer to move back to the farm that I grew up on. And I'm operating now in the hospital that I was born at and it's all coming together.

But at that time when it was just a vision, something to look forward to, I'm finding Tyler Hughes right on the Internet, which we're both older than. And so I had to look you up. And then in residency, I was looking for a job, basically something to help me pay my student loans off. And I knew I wanted to be a rural surgeon. I ended up interviewing in Nevada, Missouri, and I was close. And I said, how far am I from McPherson? And we came in the Cessna 172, my wife and I. And I said, I got to get over there and would it work out. And then sure enough, Dr. Hughes takes me and my wife to Applebee's and buys us dinner and got to see the actual place where the magic happens. So we have a little bit of that special history. I just wanted to share about that. And that would have been in about 2016. So you practiced for how much longer than after.

Dr. Tyler Hughes: [00:07:34] That was July, at the end of July 2016. So must have been just a few months. Right when we were trying to decide what the heck I was going to do at that time. But that was a great day. I remember it well.

Dr. Randy Lehman: [00:07:49] And you had some... You told me that you had flown in the past. Are you doing any flying now? I mean, you never lose your pilot's license.

Dr. Tyler Hughes: [00:07:56] But I'm not flying anymore. There are two reasons for it. Number one, all these other things burned up all the time to practice, as we all know, whether it's the operating room or flying, if you don't practice, you could come to a bad end. I didn't want to be that to be my final Internet headline. And plus I dragged out the engines on my twin-engine Beech. And you know, that was a lot of money. I tell people it's cheaper to have a cocaine habit than to fly, but I loved it. I did it for, I think something like 29 years. And it was very useful, especially when I moved to rural world, because I could fly to meetings. I could fly and help other surgeons in other parts of Kansas. Just fly out for a day and fly back. It's really fun. Do you have time for a quickie story about that?

Dr. Randy Lehman: [00:08:57] Absolutely, yeah. Anything for aviation story.

Dr. Tyler Hughes: [00:09:01] Sure. I had a friend in Smith Center, Kansas, Pam Steinle, who would call me to please assist every now and then. And so I flew up the Baron one day, and I landed at this little, you know, probably 4,000, maybe 3,500-foot strip in Smith Center. And I taxied up, and there were people at the airport, and it was... People saw a plane flying in, and they drove out to see who it was, because they don't see planes fly over all the time. And then one of them said, "You must be coming to help Dr. Steinle." So, yep, I got a ride into town, which was about three minutes, did the operation with Pam, and flew out. That was fun, man.

Dr. Randy Lehman: [00:09:56] See, these things are... The only place this can happen is in the rural United States. Like, it has to be both of those things, you know? That's fantastic. Well, we've kind of touched on your interest in rural surgery, and one of the questions I like to ask every guest is, why is rural surgery important to you? I make it sound like I've done tons of these episodes. I basically got the Godfather to come in for my very first ever recorded interview here. I've done a few practice ones, but this is the one that we're planning on releasing first. But the main question is, why is rural surgery so special to you?

Dr. Tyler Hughes: [00:10:33] To me personally, or as a concept?

Dr. Randy Lehman: [00:10:37] Well, why is it special to you as a concept? Let's start there.

Dr. Tyler Hughes: [00:10:42] Okay. So I didn't know it was going to be so important as a concept. When I left Dallas, I just wanted to get out of the rat race and take care of people. But in the intervening years, I found out how desperately surgery is needed in rural America and how hard it is to get a good surgical team together, because there's an enormous need.

When I was in Dallas, I was receiving transfers in from rural areas of Texas. It was always like, what the heck are they doing out there? Everything that comes in is a train wreck. And actually, one of the reasons it's a train wreck is that rural people had no place to go. And by the time they got to someone who said, "You really need a surgeon," their case was already pretty advanced. So one of the great things that I discovered is we can reduce morbidity and mortality. It's not just convenience. Delayed care causes poor results. And most of the delay in rural is because we're losing our rural surgery workforce and our rural surgical teams.

So that's... that's why for me. The other, the personal part of why rural surgery is important... Yeah, you couldn't drag me back to Dallas with a team of wild horses. I live three minutes from the hospital. I basically can do any operation I want to do. And of course, that puts a heavy load on the surgeon to know their limitations, make sure you're adequately trained. And I... One thing that will never prepare you for in residency is you're going to see that patient after discharge, at the drugstore, at the gas station, at Walmart. And over a period of time, you begin to realize what a great service you've done for your community and why you went to medical school. And so I felt fulfilled every day. And so two great reasons: there's a huge need, and it's incredibly rewarding. I bet you found the same thing true.

Dr. Randy Lehman: [00:13:11] Yeah. I'm four years out of training now, and same deal. So go to the gas station and the person working behind the counter, you can't see the scar on her forehead from her skin cancer that you took off a couple months before she was getting married. And you know the backstory, you know, to all these people, it's like, it's really cool and crazy. And there's also before... So I grew up here and I... I wanted to come back and help this community before I knew I was going to be a doctor and before I knew that I was going to be a surgeon. That's a long story for another day. 

But there's other reasons outside of just my personal practice, too, why it's a very symbiotic relationship between hospitals and surgeons. You can't really have a rural surgeon without a hospital, and you can't often have a rural hospital without a surgeon. So we have to work together. And there's a lot of value to the community in terms of if the hospital stays open. If you equate the hospital staying open with surgery, you know, which... That's maybe putting a little too much pressure on us. But in a lot of times, it's true.

Each surgeon brings 25 jobs to the community, is what the papers would say. And if you're talking about bringing jobs, those are good-paying jobs, quality members of our society that are paying our taxes. And then at the same time, you know, you increase the business climate. Often your hospital is one of your top three employers in your county.

But also in order to bring in other businesses that can thrive in our small town, if they know that there's a hospital there, that makes a difference, because they'll be able to have a workforce that will stay there. And so there's all of these other downstream effects just for the general good of your county outside of the one-to-one. And I get a great fulfillment on the one-to-one too. But being part of that whole system as an agent of change, I don't necessarily think everybody thinks about it the same way as me, but that is my opinion.

And I have one more question though. In terms of the challenges for rural surgery, you said that putting a trained surgeon out there is maybe the biggest challenge. I'm a trained surgeon. I'm passionate about rural surgery. I went to the Mayo Clinic in the rural surgery track. I did 1,600 cases. I'm motivated, I'm ready to go. I find other issues. Anesthesia can be a big problem. Not just getting the warm body in place, but having somebody that's willing to take any element of... There's no such thing as zero-risk surgery.

So I have a 14-year-old patient with a mass on her eyebrow, subcutaneous mass of her eyebrow. Can't take it out in clinic, it's a little too much. Tried to list it for elective resection and I was told that we don't do any elective general anesthesia for a patient under age 18. And I said, what about an appy? Well, appy is different because it's emergent. I'm like, it's a perfectly healthy 14-year-old.

And so what's the right thing to do and where do you draw the line on risk? That's one problem. Nursing and other staffing can be another problem. And then finally this whole concept of the spoke-and-hub model, as we move away from the county hospitals and they become acquired by the Franciscans, the IUs, the Mayo Clinics, the KUs of the world, suddenly the decision-making power isn't at that hospital anymore. It's up the chain and down the interstate to somebody who maybe visits once or twice a year, but doesn't really know or have any say in the community or honestly just doesn't really have a reason to care about that community. It's not their fault they've got bigger fish to fry. So can you comment on some of those other barriers and how we can fight them to allow the rural surgeons who actually want to be out there caring for the communities to get their job done?

Dr. Tyler Hughes: [00:17:34] If you look back about 2015 at the Lancet Commission on Global Surgery, they identify some of the issues that you just talked about, especially that the fix is not just parachuting a surgeon into a community. You're absolutely right. You have to have anesthesia. You have to have a family medicine group that understands what the capabilities of a general surgeon are. And you need anesthesia as well. 

And that doesn't even speak to the nursing situation. A lot of that can be solved by doing some training in rural environments. You knew because you grew up in that town that it was possible. Most of the students joining any allied health profession or medical education think that it's impossible to do surgery.

When they learn it as, quote, "children," they understand that it is very possible. So we have a generational issue. We've got to start now and change the paradigm so that people understand that rural is an option. The issue of anesthesia, I don't know if you're using MD or CRNA anesthesia.

Dr. Randy Lehman: [00:19:12] I'm actually... now I'm in three different critical access hospitals in a little triangle. One place has all MD anesthesia. The other two places have CRNA. And this, the one that I was at, actually is not exclusively CRNA. It just happens to be usually a CRNA who's very skilled and good and honestly would be comfortable himself doing it. But it's an IU policy at this hospital that we don't do any patients... there's your spoke-and-hub model... under 18. And then I said, well, do you want me to send it down to Lafayette where they can do it there? They said they don't actually do elective surgery on patients in Lafayette, town of 200,000 people. They all have to go down to Riley, which is two hours away from where I live.

Dr. Tyler Hughes: [00:19:59] That's policy that needs to be changed. There are 13 million children in rural America at the best guess. I just don't think they're well served by refusing to operate on them. So it's interesting at first, and we were CRNA only—they were very well trained. And we did kids from... We had ENT in town. So he was doing one and two-year-olds with ear tubes under general. And we had a great safety record.

The issue, and this comes from larger academic centers that produce papers saying it's greater risk for the child. And they're even talking about having to have fellowship training in order to put to sleep, you know, a pediatric patient. I'm just not sure the risk-benefit equation is there on that. And I do think we as a profession need to push back and say CRNA anesthesia is pretty well trained in this country and we need them.

If anesthesia is not going to come out to us, then from an ethical standpoint, I don't think a child ought to be forced to take increased risk of transfer. How would you like to be a little kid in a hospital 200 miles away and only mom or only dad can come see you? Or maybe neither for a while because they have to work in order to pay that medical bill. And what happens when you have a complication? Yeah, but in both extremes of age, I think about my elderly patients who have lots of comorbidities and nobody knows the old, you know, "a haircut would kill them" sort of patient. Well, you can't make them more dead. And transferring them 200 miles away, I'm not sure that really is in the patient's best interest.

So I think we do need to push back on those policies and advocate that we get these surgical teams and develop networks. I don't think the hub-and-spoke model is a great model for rural. We don't really use that in trauma. Trauma has various levels of abilities all over the place. And so I prefer more of an Internet model where there are lots of nodes of care, some with special expertise, some with general expertise that we could then utilize continuously. Yep.

Dr. Randy Lehman: [00:23:00] Yeah, that sounds like a great idea. I've been back and forth on the hub-and-spoke model, but off of it less and less.

Dr. Tyler Hughes: [00:23:07] Take a look at COVID-19. How did it work in COVID-19?

Dr. Randy Lehman: [00:23:10] Right.

Dr. Tyler Hughes: [00:23:10] Not so good, did it? That little kid who's sick... Especially if they're sick. I mean, it's ironic. A healthy kid you can't put asleep, but you can a sick kid.

Dr. Randy Lehman: [00:23:23] Right. That's what I'm trying to understand.

Dr. Tyler Hughes: [00:23:25] I'm sorry, that doesn't make sense to me. So, you know, in COVID-19, our experience in central Kansas was we were doing everything for a long time, and it's still happening. And the administrators of the various hospitals said, "Huh, we can do a lot more than we thought we could. Maybe we ought to take a look at that lesson."

Dr. Randy Lehman: [00:23:52] It's a good lesson. I think we should move to the next segment, which is "How I Do It." This is the segment that I'm probably most excited about with my show, which is where I'm going to dive in deep with each guest on just one case, really deep, extreme detail. How do you hold your needle driver or your pickups? What exact suture do you use? How big are your bites? That kind of stuff.

And so for you, we've kind of discussed maybe talking about right colectomies. I did one last week, and so it's on top of my mind. And then you shared a little bit about how your practice changed over time. It started, obviously, open colectomies and then as laparoscopic, you know, became in vogue, you changed. So shall we start with maybe saying in the '80s in Dallas, a patient has a right colon mass and they need a right colectomy? At that time, you're getting tissue diagnosis by colonoscopy first, most of the time, I would say, and so say it's proven adenocarcinoma and now you're going to do a right colectomy. Before the patient got to the operating room, what medications were they getting and did that change through your practice as well?

Dr. Tyler Hughes: [00:25:19] So the pre-op care was fairly identical. They were, of course, tortured with a mechanical and antibiotic bowel prep. They were usually... they were in the hospital in the early '80s. They were in the hospital the day before with an IV while we purged them. We do that now all outpatient. And so you have people dry as potato chips coming in to have their colectomy on a nearly outpatient basis.

So pre-op was hydration and assessment in hospital, and then we would classically take them to the OR after their prep. I'd say in Dallas, 99% of them were done through a middle midline incision and, you know, retroperitoneal approaches or lateral approaches, at least in Dallas in the '80s just wasn't used. We kept them in the hospital until they passed gas and were tolerating diet and walking the halls, which I would say in general was between five and 10 days, depending on the case. A lot of them had nasogastric tubes in them when they came out of the operating room.

Dr. Randy Lehman: [00:26:42] Sure. So in the operation, I'm imagining there might be medical students listening to this podcast, certainly residents, young attendings. I don't know if I want to go to the level of detail of "did you use a #10 blade scalpel to make your skin incision?" But I do want to really focus on like if somebody's never seen a colectomy before. Let's talk about what are the steps. So you make a skin incision with scalpel, dissect through the subcutaneous tissues, then you encounter fascia. How do you open the fascia?

Dr. Tyler Hughes: [00:27:14] So my technique was I would make the incision through the skin, subcutaneous tissue, maybe not entirely. My assistant and I would grab the subcutaneous tissue on either side and pull. It wasn't a tug of war, but each one of us would pull oppositely and the subcutaneous tissue would split right down to the midline.

I don't know... these days, open surgery is fairly uncommon, but it's really easy. When you go to make your incision on the fascia, where's the midline? And you miss the midline, now you've exposed the rectus. That technique of pulling on either side and letting the tissue part along its natural plane pretty much points the midline out to you. So that's the way I would enter the fascia.

I only cut the fascia. I try not to cut the peritoneum, which was, you know, depends on the patient, but usually pretty easy. Fascia would come apart if you're in the midline easily. Then I'd take two hemostats and grab the peritoneum and tent it up, take the end of my scalpel blade, and see if I could see it through the peritoneum. If I couldn't see it, something's wrong. There may be a loop of bowel or omentum. And so we would try another location.

And sometimes if it was real thin, I would just poke with my finger a little bit and see if I could make a hole, because small bowel and omentum won't do that, but peritoneum will. Is that sort of detail you wanted?

Dr. Randy Lehman: [00:28:56] Yes. Those are excellent tips. Thank you so much. And it makes me think right now when I'm doing open surgery on these morbidly obese patients...

Dr. Tyler Hughes: [00:29:06] It's great. Yeah.

Dr. Randy Lehman: [00:29:09] Seeing... seeing that scalpel blade on the back side of the peritoneum when, you know, we've got so many layers of fat. That's the one issue that I kind of run into. But if you can keep going through the fat, I guess down into it. So you always open the fascia with a scalpel then and then try to find that peritoneum behind, right?

Dr. Tyler Hughes: [00:29:25] Yeah.

Dr. Randy Lehman: [00:29:25] Yeah. Okay. So then once you got in, you extend your fascia, then... sharply?

Dr. Tyler Hughes: [00:29:31] Yeah. Full length of the incision. Sometimes I would use cautery, but, you know, there's some controversy of whether cautery is more harmful than helpful. But I saw surgeons doing both. I like to do it sharply. If you're really in the midline, it doesn't bleed very much when you do that.

Dr. Randy Lehman: [00:29:49] Okay. And then did you use a special kind of retractor?

Dr. Tyler Hughes: [00:29:54] So I was a big fan of both the Balfour and the Iron Hand retractor. They wouldn't move like my assistants would. So generally, I like the Balfour because I can... There's a large oval ring that attaches to a vertical bar so you can set your retractor in any position.

Dr. Randy Lehman: [00:30:21] How many centimeters off the skin would you say you put the Balfour ring?

Dr. Tyler Hughes: [00:30:26] About 2 cm. I never wanted to have it squishing the skin because you wake up and there'd be a bruise. It's like an early decubitus ulcer. So you do have to watch out. And you sure don't want to ratchet that retractor back to the point that it's pinching anything or dragging tissue into it.

Dr. Randy Lehman: [00:30:51] And did you angle the ring at all, or was it always flat?

Dr. Tyler Hughes: [00:30:55] It usually was flat, but it depended on the patient and the quadrant, and then the orientation of the oval depended on which way I wanted to go in the abdomen.

Dr. Randy Lehman: [00:31:06] Okay, so we've got a vertical midline, we've got our Balfour in place. And then how did you start your colectomy?

Dr. Tyler Hughes: [00:31:12] Actually, I don't start the colectomy at that point. It's easy to forget that you get a free CT scan called an exploratory laparotomy. And so the first thing I would do is search every quadrant of the abdomen, because despite what the CT tells you or the sonogram or your referring doctor, every now and then, "uh oh, what is that in the liver?" So I evaluated the liver. I was committed to colectomy at that point, you know, when you're open. And we did not resect liver metastases in the '80s, so it's a whole different story. But a careful abdominal exploration demonstrates first.

Dr. Randy Lehman: [00:32:03] So if you had, like an omental mat, you would have probably taken that out?

Dr. Tyler Hughes: [00:32:07] Yeah, take it out, send it for frozen section. Not so much for treatment, but for staging.

Dr. Randy Lehman: [00:32:12] Right. Okay. So then you're carrying on with your colectomy, and you did lateral to medial?

Dr. Tyler Hughes: [00:32:17] The right colectomy is a great case because it's really the chip shot of colon surgery. One thing I did, if it's a tumor case, back in those days, I would take an umbilical tape and tie off the area above and below the tumor. George Block and others did studies about no-touch technique. So the goal here is not to touch the tumor. So you tie it off so you can't squish the tumor and shoot cells, you know, distally into your remaining colon.

I don't know if that still holds true today, but that's the way we did it. Then next I would start in the right lower quadrant, near where you'd expect to find the appendix, and mobilize the right colon from lateral to medial, which is, of course, opposite to what people do generally laparoscopically. Find the hepatic flexure, divide it between Peans, continue in the avascular plane along the omentum, identify the middle colic artery. And generally just to the right of the middle colic artery's branches into the colon is where I would divide. And approximately.

Dr. Randy Lehman: [00:33:47] Did you find the right colic?

Dr. Tyler Hughes: [00:33:49] Yes.

Dr. Randy Lehman: [00:33:51] How did you find it? How did you find the middle colic? I'm sorry.

Dr. Tyler Hughes: [00:33:54] You just pull up the omentum, palpate along the midline of the colonic mesocolon. You can usually, in a thin patient, you can just see it. Another neat trick is to lower your operating light and transilluminate and you'll see the middle colic. And there's the right colic and the ileocolic branch and the collaterals. Once I had identified those, then I would tie off the right colic vein followed by the right colic artery. I usually did the vein first if I could because I didn't want to continue to pressurize potential tumor cells that were circulating.

Dr. Randy Lehman: [00:34:44] So what did you tie off with?

Dr. Tyler Hughes: [00:34:47] Usually, usually 2-0 silk. In later days, I used, I was fearless and used Vicryl. I can remember vividly the first time I divided them with either a ligature or a harmonic scalpel. And you know, it was like, I think this is going to go badly. But the ligature worked really well. Even on those big vessels, it still makes me uncomfortable.

Dr. Randy Lehman: [00:35:15] Yeah, I haven't given up my ties on my...

Dr. Tyler Hughes: [00:35:17] Yeah, I think if you do ligature on fairly big vessels, maybe that's your secondary. Tie off your primary should still be good fashion suture. So then I've got that. I divide the colon in... Mark Ravitch had just introduced the staplers in those days. And so about half the time I used the stapler GIA in a functional side-to-side, end-to-end technique. And then another stapler, close defect. But I actually, even until the last days of my practice, I always preferred a hand-sewn anastomosis. And for colon surgery, I always did that in two layers.

Dr. Randy Lehman: [00:36:08] Okay, so we're going to talk about the details of the hand-sewn anastomosis. But before, just if there is a student or a resident... I'm sorry for the practicing surgeons, 20 years out, but we have now divided the terminal ileum and the transverse colon. The specimen is out with its branches, and you can look that up in the textbook if you don't know. And we're lining them up side by side with the two ends together, and we're getting ready to make a connection. So it's a hole in each limb. And then one way to do stapled, which is what Dr. Hughes just described, is a linear cutting stapler coming down the middle that's got two rows of titanium staples on either side. I'm assuming you're using a 3.5-millimeter blue load, right?

Dr. Tyler Hughes: [00:36:49] Actually, they didn't even come in colors at that time. There was just a GI load and a vascular load.

Dr. Randy Lehman: [00:36:55] Okay. So that the height, you don't want it too tight, you don't want it too loose on the staples. But 3.5 is a typical blue load. Blue for bowel, that's something you can remember. And then that common enterotomy where that stapler went into now needs to be cut off. And so you can do that with a second staple load or you can sew it. And these are the details that I'm asking. There's no right or wrong answer on how to do it. Asking Dr. Hughes, how'd you actually do it when you were a surgeon? Now he's telling us that sometimes he would tie it in a hand-sewn fashion. And that's a two-layered connection. So walk us through, very detailed, step by step, exactly what you did with your hands and your assistants.

Dr. Tyler Hughes: [00:37:34] Okay, so you have the hole, so to speak, where the GIA stapler has made it. And it's kind of an oval hole like this. And of course, I have bowel clamps on so we don't get, you know, backflow. Always try to prevent spillage. We would put those bowel clamps on before we actually fired the GIA.

By the way, little hint, always look at your staple line through that opening if you can. 3.5 staples are exactly the right size, but they don't actually close all the way. They don't... You know, it's supposed to be a B shape. I'm sorry, in two dimensions, this doesn't work. But it's supposed to be a B shape, but the B doesn't... All the limbs of the B don't come all the way down. That's normal. But if you have one vessel in between a staple and it's arterial, you may have a comeback later in the day. So always check for staple line bleeding.

Okay, so back to the two-suture technique. I put a Lembert suture on either end and put a hemostat on it so it holds the anastomosis up where I can see it without moving. Then I use a simple running, usually 3-0 Vicryl—a little mineral oil on the Vicryl makes it glide through the tissue and not saw the tissue. Now run that from far away toward me until I close the defect. And then I put a series of Lembert 3-0 silk sutures covering that whip stitch that I put in as the first layer.

Dr. Randy Lehman: [00:39:32] And then your first knot on your running Vicryl. Do you put that inside the bowel or do you just go out to in, in to out and then tie on the top?

Dr. Tyler Hughes: [00:39:43] I don't think it makes a lot of difference. I tended to be...

Dr. Randy Lehman: [00:39:46] Because you're burying it anyway.

Dr. Tyler Hughes: [00:39:48] Sorry.

Dr. Randy Lehman: [00:39:49] Okay. Because you're burying it anyway with the Lembert, right?

Dr. Tyler Hughes: [00:39:53] Yeah. I wouldn't want it sticking out if I were not doing a second layer. And remember that that first layer is actually what heals—the Lembert sutures are not helping you that much. It's the mucosa-to-mucosa healing. So you need to make that a nice watertight but not strangulating suture. And that's the other thing. I point out that beginners frequently overdo. When you put in the Lembert and you tie them down, you approximate not strangulate. That knot needs to be just tight enough to hold that inverted position.

Dr. Randy Lehman: [00:40:35] Yeah, I haven't... This isn't me doing the "how I do it," but why don't I just offer... One thing that I got from training is you're not throwing your stitch for how it looks right then. You're throwing it for how it looks 24 to 48 hours after the swelling sets in and the third spacing sets in, which is going to make whatever knot you tie tighter. And if you have a leak on day three or four, a lot of times it's from tying that stitch what looked like good at the time of surgery, but then that extra swelling pulled the stitch through and boom, you can leak at it at one of those stitches. I haven't personally seen it because I've been extremely paranoid about that, you know, because somebody taught me. But these are the kind of things I'm trying to bring out in these discussions. So you're talking about... Go ahead.

Dr. Tyler Hughes: [00:41:22] You're absolutely right.

Dr. Randy Lehman: [00:41:23] You're talking about closing the common enterotomy, right?

Dr. Tyler Hughes: [00:41:26] Yeah.

Dr. Randy Lehman: [00:41:27] You're not really talking about close... Doing the whole thing hand sewn. It's... You're going to do one staple, then you're going to close the common enterotomy hand?

Dr. Tyler Hughes: [00:41:33] So, yeah, if I'm doing a full-out anastomosis, it's basically the same technique. Sutures, Lembert at the corners, do the posterior line and that knot's always inside. Run it around. And then I usually start a second suture and run it toward me.

When you're teaching, it's a great, it's a great technique to teach by you yourself doing the back row, which is the harder. And then you can help your resident or assistant do the front row where you can see very well exactly what's happening. Now the other thing we do...

Dr. Randy Lehman: [00:42:15] Yeah.

Dr. Tyler Hughes: [00:42:16] Is we put that first row of Lembert sutures. You put those two silks in and in the posterior row, you put your Lemberts in. You don't tie them until you put them all in. Then you tie, cut them, and start your internal layer. It's a lot easier when you see it than when you try to describe it.

Dr. Randy Lehman: [00:42:40] Yeah. And it's a podcast and some of you, you know, I'm seeing you on video, this will be on YouTube, but it's also going to be on Spotify and podcast apps. And so some people will just be listening to this audio only. It's going to be, you know, but that's... We write our op notes with just words. So that's good. Was there anything else then? Did you close in your right colectomies, did you close the mesenteric defect?

Dr. Tyler Hughes: [00:43:04] Always closed it, but never sacrificed the vessels in the process. And yeah, you know, I think it's a good idea. I think it's good practice to do it. But I will tell you, some of those closures have already failed before you put in your last stitch. The mesocolon is very thin in some people and you do not want to take big bites of the mesocolon because you're gonna... You may catch the blood supply to your anastomosis, and that's a disaster.

Dr. Randy Lehman: [00:43:41] Of course, small bowel, it's easy always to get the mesentery defect closed, but right colectomy in particular, I mean, that's a very wide mesenteric defect. So I saw it both ways in training. I do it if it's easy, basically. It's kind of how I've been doing it. So then you close up... Well, you do... Do you irrigate the abdomen or any other things before you start closing up?

Dr. Tyler Hughes: [00:44:02] I did. I'm not sure it's necessary. Potentially it could be harmful. But I usually put a liter or two in and then suctioned it out.

Dr. Randy Lehman: [00:44:14] Yeah. And what did you use to close the fascia?

Dr. Tyler Hughes: [00:44:20] So my technique, and I kept this basically forever, is I used number 2 Vicryl for internal retention sutures and a running monofilament Prolene in between the internal retention sutures.

Dr. Randy Lehman: [00:44:47] Okay, and what was the number on the... Was it a 0 Prolene or a 2-0?

Dr. Tyler Hughes: [00:44:52] You know, in the early days, I thought the bigger the sutures, the better. So I was practically using, you know, stuff that you could tie your boat up with. But I think a 0 is good enough for most patients. It looks to me like now smaller bites and closer travel is more effective than great big suture. The internal retention on that... Yeah, the internal retention sutures save you if you have a partial failure so you don't get an evisceration. I really don't like just a running suture on the midline.

Dr. Randy Lehman: [00:45:44] All right, well, these are the things we want to talk about. And then you never closed peritoneum, correct?

Dr. Tyler Hughes: [00:45:50] Actually, I didn't pay a lot of attention to it. A lot of surgeons closed the midline because they thought it caused less dense adhesions to the midline. To me, the most important thing is careful approximation of the fascia. That's what, you know, if you get mesothelial cells growing in between your fiber... fiber cells, then you may have defects long term.

Dr. Randy Lehman: [00:46:18] Yep, that makes sense. Did you close subcutaneous or was there a... Somebody would get it and somebody wouldn't?

Dr. Tyler Hughes: [00:46:26] If it was a real clean case, real clean case... I'm doing it for cancer. I consider that clean-contaminated. So I did a very loose approximation subcutaneous.

And in those days, we used the staples, but we used to use vertical running mattress sutures, which really made a good imitation of railroad tracks when you took them out. So I was glad skin staplers came along. And later, subcuticular suture was my favorite closure for the skin.

Dr. Randy Lehman: [00:47:06] Okay, well, that's really nice detail. Thanks for just, you know, digging through. Now, you did say that later in your career, you had transitioned to doing Enhanced Recovery After Surgery protocol or ERAS, and doing some of these cases laparoscopically. I don't want to take too much time on it, but what would be some of the main technique tips? I mean, you were an open surgeon that had to learn laparoscopy. What made it a lot easier for you to do this laparoscopically?

Dr. Tyler Hughes: [00:47:39] Actually, it was never easy for me laparoscopically. As a matter of fact, everything that's easier for the surgeon is usually worse for the patient. I still, you know, I tried the medial to lateral approach, and I would sometimes use lateral to medial. I actually started out doing laparoscopic surgery by doing the freeing of the colon laparoscopically and then making an appendectomy-sized defect, bring out the colon, do my division and then anastomose, usually by hand, and then dropping it back in. I actually found that an excellent way to transition.

We didn't have V-Loc™ sutures by the time I finished my primary surgical career. I'm sure today I'd use V-Loc™ to do the anastomosis with. That's what my younger partners do.

Dr. Randy Lehman: [00:48:45] So let me just say real quick how I did mine because I really don't think there's a right or wrong answer to these things. And a lot of times I agree with what you're saying. Sometimes the technically easier thing for the surgeon is worse for the patient. But at the same time, if it's technically easy surgery for the surgeon, a lot of times that's good outcome surgery. The pain... Pain is one big question. But good outcome surgery, when you can see what you're doing and it's easy. When the surgery feels hard, that's when I'm worried. Am I doing something?

So I have been doing most of my colon surgery hand-assisted. I don't know where I'm at in terms of majority and minority, but my outcomes have been wonderful. And the patients, I use some Exparel for the pain afterwards. And so this particular case I did hand-assisted right colectomy. It was for a mass of the ascending colon that had been diagnosed by me on colonoscopy. That was high-grade dysplasia on the biopsies and I didn't actually catch adenocarcinoma—was highly suspicious and sure enough was confirmed on final pathology.

And so I put an upper midline 10-centimeter incision that's as big as my hand. And then I'm going to have to make some kind of incision to extract the specimen, whether that's 4 or 5 centimeters, you know, and then I put a lower midline port and then a port on the other side. And I, in this particular patient, it was just right there. I did a lateral to medial approach. I have done medial to lateral as well, but I just keep mobilizing until it gets to my hand port and I take the omentum off, take down the hepatic flexure.

I use a blunt tip 5-millimeter Ligasure to divide a lot of things and I use a hot scissor quite a lot. And I've got my one hand in with a double glove on. So I've got an under glove indicator and an outer glove. And then I wrap Ioban™ around my hand and next, you know, 10 minutes later or less, it's extracted and I've got the medium Alexis wound retractor, which is the base for the gel port. Then I bring the specimen right out and I do the anastomosis exactly as you described, which you were doing in the '80s. And then, you know, basically drop it right back in, wrap it around with omentum. Sometimes I will take the anastomosis off with this or the common enterotomy off with a stapler.

But I usually hand sew it with two layers just like that, because you got to still sew on bowel every once in a while. And then I close with the running single-stranded monofilament, my fascial defect. And then usually if it's no contamination, then I do exactly what you're saying—a subcuticular like 4-0 Monocryl. But staples, if I'm worried about contamination or whatever, usually don't close it all the way, but sometimes will pack a little bit. And that guy did great. Went home in two days. And the final pathology, 0 out of 50 lymph nodes positive, big tumor. Like I can't... It was 8 cm or something like that. So hopefully he does well, you know, 40, 45-year-old guy in my community, so...

Dr. Tyler Hughes: [00:52:00] So did you say 0 out of 50?

Dr. Randy Lehman: [00:52:04] 0 out of 50, yeah.

Dr. Tyler Hughes: [00:52:06] And so do you have a depth of penetration? Did it go to serosa or...

Dr. Randy Lehman: [00:52:15] It was definitely not to serosa. I think it's going to be a T3 because of size.

Dr. Tyler Hughes: [00:52:20] Yeah. So he'll probably...

Dr. Randy Lehman: [00:52:21] I don't have that right in front of me.

Dr. Tyler Hughes: [00:52:24] Don't you think?

Dr. Randy Lehman: [00:52:26] Just because I'm gonna let the oncologist decide that. Yeah, but we'll definitely refer him for that. And in my preop workup too, for the residents and everything is, you know, you make the diagnosis, name it, stage it, treat it. That's how you treat cancer. So first you name it by getting a colonoscopy and a piece of it. And then in this particular patient, I didn't trust that it was just high-grade dysplasia. But I did not rescope him. But I did do all the staging workup ahead of time. So I got a CT chest, abdomen, pelvis and a CEA. That's basically your staging workup for your colon cancer. And then went ahead with the colectomy because it's going to need it regardless. Making sure that I got a good lymph node harvest.

Dr. Tyler Hughes: [00:53:08] You know what's great about rural surgery? Is that your follow-up is almost 100% and you'll know his ultimate outcome. I had several tumors like that. My word, this is a big tumor. Even those involving abdominal wall. And this does happen in right colon surgery. You know, it's not always just pluck out the right colon and right... You know... My anecdotal experience for what it's worth is those larger tumors with no lymph nodes do unbelievably well. You really think that they're not going to do well. But they, you know, for some reason if they don't have lymphatic invasion and they don't get the serosa, it's better for them than otherwise. Great case.

Dr. Randy Lehman: [00:54:05] Time will tell. So let's move on to the financial corner. We can take three to five minutes here if you don't mind. Do you have a particular money tip to share? Maybe it's a mistake you made or maybe it's a genius move you made for that resident junior attending, how they can set themselves up for success financially.

Dr. Tyler Hughes: [00:54:27] Actually it's pretty easy. Number one, be a saver all your life, you know. Number two, don't accelerate your lifestyle immediately after training. You know they're going to offer you a lot of money and you're probably going to get more money than you ever made in any five-year period of your life the first year. But if you'll maximize putting that into your retirement fund... Do not buy the biggest house, do not buy your first Porsche that year and pay down your debt. The magic of investing over time is unbelievable. That's exactly the course I followed. There's never a good time to be out of the stock market. I was in the stock market in 2008 and you know, I didn't bail like so many people did. You're in it for the long term if you're young and you can tolerate lots of shocks in your portfolio. So save, don't overspend and by the time you're 10 years out, you're going to be sitting pretty. You know, the rest of it is just enjoyment at that point.

But youth is your biggest weapon against, you know, having to work the rest of your life. I will tell you, you'll probably work the rest of your life because most of us surgeons are addicted to surgery and we can't do without it. But you'll be able to. The other thing about that is if you save, if your situation changes, you can walk away without financial disaster. And we do see this in rural surgery. So it's important to always have that six months to a year money set aside just in case. Not very sophisticated advice, but it works.

Dr. Randy Lehman: [00:56:35] But I think that's the key. It's actually a habit rather than some big, you know, I didn't really expect you to come on here and say, "Well, I just hit it out of the park with this one stock pick in the mid-80s and I set myself for life." It's more of exactly what you described. So thanks for reiterating once again for us. Let's move on to this next segment, which I'm calling Classic Rural Surgery. Do you have a case personal story that is just classic rural surgery?

Dr. Tyler Hughes: [00:57:15] Well, I think I love this story. I love it and hate it because the first part's really sad. You know, we had a two-room emergency room at McPherson at the time and I was called in for a terrible accident where a 14-year-old had been rolled over on in a truck and was in cardiac arrest as I got there. So I'm doing CPR and trying to see if there's any way to save this patient.

And the ER doc, who happened to be a resident moonlighting from Wichita, sticks his head in the door and says, "Dr. Hughes, when you're finished with this, I've got something really serious in the other room." You know, I look up from a resuscitation going, "What's more serious than this?" I think he should have said much more amazing. We did finish up with that unfortunate case.

I walked into the other room to see a lady up in lithotomy position, appropriately draped with about four feet of small bowel hanging out of her vagina. She had ruptured an enterocele from an old hysterectomy. And I looked at that and I said, "Pretty sure we got to put the insides back from the outsides." We took her around, did a laparotomy, just literally hauled out the bowel from the vagina, did a reclosure of the vagina, irrigated and closed fully expecting abscesses, bowel obstruction, terrible outcome. Patient left in four days and lived happily ever after.

So I share that story because you have these incredibly tragic things that you have to deal with that are actually very personal. And then you have these triumphs of something weird that just walks in. She walked in saying, "I don't think this is right" and just shocked the ER resident something fierce. And really opened my eyes too when I saw it was a classic rural situation.

Dr. Randy Lehman: [00:59:54] Yeah, we have these issues now with the OB-GYN or OB departments closing in rural hospitals. And then a lot of times then you maybe had some element of OB-GYN. Now you have even less. And that the GYN stuff is not... This is sort of an ax I might grind on this podcast. It's not really anything to be scared of. I think you need to have somebody, you know, that you can communicate with and have a great professional relationship with. But I take care of a lot of benign GYN things. Last week I did an ovarian torsion. Those type... I do hysterectomies with my partner for benign conditions. I do tubal ligation, which I do as a laparoscopic bilateral salpingectomy. And the patients generally do quite well. Your pelvic blood flow is excellent. So thank you for sharing that. And I just had one follow-up question. How did you close the vaginal cuff?

Dr. Tyler Hughes: [01:00:48] As I recall, we used a series of zero silk sutures, and then we anchored what we could find at the round ligament to that closure to try to prevent prolapse of it. You can use absorbable, but since she had already eviscerated through there, I take that back. I didn't use silk.

I used monofilament because I was worried about the contamination. I didn't want those interstices of silk to harbor the bacteria that could cause a pericuff abscess. But again, she's already herniated through there, so we needed to get as strong a closure as I felt like we could. And we used interrupted sutures. We did not... we did not run that because the running sutures, it's nicely hemostatic, but bleeding wasn't our problem at the time. It was crummy tissue.

Dr. Randy Lehman: [01:01:50] Yep. All right, well, that's wonderful. And one more question now that I still come up with is, so did you have a GYN that you... you had a good relationship with, either in town or out of town that you could call if you had technical questions on things like that?

Dr. Tyler Hughes: [01:02:05] I really didn't have a lot of backup on GYN for many years. We... Well, I'll take that back. The first year I was there, we had an OB-GYN in town, but she left. And so it was about 10 years with no backup. And I had one or two people I could call in Salina, but most of the stuff I was seeing, like you said, I knew what to do. You know, if it's bleeding, stop the bleeding.

Ectopic pregnancies were really an issue before methotrexate treatment became standardized. And so I had hemoperitoneum—the answer to that is stop the bleeding. I learned how to save tubes, etc. But again... And Randy, I took out a benign ovarian cyst the size of a Christmas turkey once and maybe I should have sent that on, but the woman wouldn't go anywhere else, which is another issue with rural patients. Don't want to go.

Dr. Randy Lehman: [01:03:23] Right now you sound like you're doing the Ephraim McDowell Danville, Kentucky thing. Yeah, the ovarian cyst and closing. And he used to close fascia, I believe, with the cobbler string. So... Good story to look up. Well, there's one last segment of the show. I just like to call it "Resources for the Busy Rural Surgeon." And so I have a feeling some of the things you might mention, but I'd like to hear it from you—some of those useful tools in your tool belt or useful groups or organizations or what you think that a rural surgeon should actually make time for on their phone, on their bookshelf, on their computer, or with their life that could help them out in their practice.

Dr. Tyler Hughes: [01:04:11] Well, I was a big believer in Selected Readings in General Surgery from the time I was a resident and the entire time that I was in practice. I always read the overview every month, especially for a rural surgeon, because you see everything and Selected Readings gives you a really great... you're never out of date. As a matter of fact, it was great for getting ready for the old recertification exam and very great for getting ready for the certifying exam. Plus, because it cycles every five years, you have all the surgery summarized every five years. Not a bad study program. Doesn't take that long to do.

So that's the resource I use. The biggest resource I use is a telephone and the relationships I've developed either with other fellows around the state or the trauma center. You gotta have a good relationship with your trauma center and then finding... I also recommend develop a good relationship with a good bariatric surgeon because bariatric cases will wander into your emergency room looking sick and they can be of great help to you.

Don't be hesitant to ask for help. And you can use the ACS Communities—just don't tell us, you know, everything. That would make it a HIPAA violation. But we have a great discussion going on right now about how to prevent seromas. And so those are things that I used. And of course I'm a meeting freak. I went to three or four meetings a year every year. And through that I learned a lot. But I also met a lot of people and it's great to be able to call someone who's the chief of surgery elsewhere and just say, "I have no idea what to do with this" or "Who should I send it to?"

And being a good referral surgeon is always a good thing. Just don't go sending someone out that you've never seen or say, "I'm not comfortable with this. Call the university." That doesn't really get you a lot of brownie points when you go to transfer.

Dr. Randy Lehman: [01:06:42] Yeah. And then it's your... it's your practice. And then you can maybe even see them back at some point in the future and kind of see what was done. It's a great way to develop your practice.

Dr. Tyler Hughes: [01:06:51] You should do that.

Dr. Randy Lehman: [01:06:52] Well, thank you so much. Yeah. So... all right, Tyler, I appreciate the time that you've taken. This has been so fantastic. You're one of my surgical mentors, one of honestly, my idols in the field of rural surgery, and you paved the way for so many of us. So it's just an extreme honor of mine to have you on as my first ever podcast guest. And I look forward to seeing you at all the meetings. Hopefully you're still frequenting.

Dr. Tyler Hughes: [01:07:19] Yeah. I'm so happy to have worked with you. And you are the future, and your colleagues of your age are the future. You need all of our support. And you'll have it.

Dr. Randy Lehman: [01:07:30] Very good. Well, thanks for listening. This has been The Rural American Surgeon, and we look forward to seeing you next time on our show. Take care.