Episode 27

Bringing Complex Procedures Back to Rural Roots with Dr. Rebekah Wever

Episode Transcript

Dr. Randy Lehman [00:00:11]: Welcome to the Rural American Surgeon. I'm your host, Dr. Randy Lehman, a general surgeon from Indiana. This show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics such as practical surgical tips, rural lifestyle, finance, training, practice models, and more. We have a segment called Classic Rural Surgery Stories, where you'll get a feel for how practice in the country differs from the city. If rural surgery is your passion, this show is for you. So now that the ChloraPrep has dried, let's make our incision. Welcome back, listener, to another episode of the Rural American Surgeon. I'm honored today to have a guest, Rebekah Wever, who just started practice with Mike Sarup in southeastern Ohio. I've been looking forward to having you as a guest for some time. So thank you very much for joining us, Dr. Wever.

Dr. Rebekah Wever [00:01:02]: Absolutely, Randy. I'm really excited for this opportunity, and ideally, you know, we can learn from each other and even help others out with this complex procedure.

Dr. Randy Lehman [00:01:11]: Yeah. A young, freshly started person who's stamping themselves as a rural surgeon is always a person that I would love to talk to. So let's start with an introduction, a little bit more of you, and tell us your background, specialty training, and how the last eight months have been for you.

Dr. Rebekah Wever [00:01:31]: Absolutely. So I grew up in this area as well, southeastern Ohio, Appalachia, Ohio, actually, and went to a really small high school here. Maybe four of us went to a college. Most of them were, you know, two-year colleges. I stayed in Ohio, went down south a little bit, stayed in Ohio for undergrad biochemistry at Marietta College, then went over to the west side of the state in Dayton for medical school. I was lucky enough to get out to South Dakota, Sioux Falls for residency mostly because I knew that I wanted to go back to southeastern Ohio and practice. I had been working with Dr. Michael Sarup, a long-term mentor. I started shadowing him in high school and went back as often as I could. He was a main reason why I fell in love with general surgery and helped me out a lot throughout my training. Now, coming back here has been an honor to be able to work with him again.

Dr. Randy Lehman [00:02:32]: So a couple follow-up questions on that. Number one, how did you find him in high school?

Dr. Rebekah Wever [00:02:37]: He's actually very well known in our community, kind of a figurehead here. Still is and will always be. But in high school, I knew I wanted to be in the medical field. Wasn't quite sure where I fit in. And you know, since he's so well known, my family's like, well, just reach out to the office and see what they can do for you. So I did, and he graciously let me just shadow him around. So that's kind of how that happened.

Dr. Randy Lehman [00:03:05]: So you didn't necessarily know you wanted to be a general surgeon at that point, and he probably significantly influenced that.

Dr. Rebekah Wever [00:03:11]: He very much did, yes, in every way. He even helped me get into the other specialties. You know, I was able to shadow our hospitalist here, oncology, you know, the whole nine yards. But definitely a main factor for why I just fell in love with general surgery.

Dr. Randy Lehman [00:03:28]: Yeah. So then when you went to South Dakota, when along this process did you commit to coming to Ohio? And what was that process like for you?

Dr. Rebekah Wever [00:03:38]: I actually knew before going into residency I wanted to work in a rural site. Ideally, for me, it was coming back home. I love the community here and again, wanted to work with Dr. Sarup. I actually committed in my second year of residency. That really helped a lot with my training and getting ready to come back to this specific rural site. As you well know, every rural site is a little different in what they're capable of and what the needs are of the community. So I came back and actually rotated here during residency. I spent two months here out of my residency total, just learning kind of what I would need to be able to do and focus on during residency to be prepared to come back here.

Dr. Randy Lehman [00:04:27]: Yeah. What a great experience. So they got you an Ohio license to be able to do that?

Dr. Rebekah Wever [00:04:32]: I did. I had a training license.

Dr. Randy Lehman [00:04:35]: That's amazing that your program lets you do that.

Dr. Rebekah Wever [00:04:38]: It was. They were very lenient, and it was tremendously helpful.

Dr. Randy Lehman [00:04:42]: And then you got to count your cases.

Dr. Rebekah Wever [00:04:44]: Yes.

Dr. Randy Lehman [00:04:44]: It wasn't wasted time. Yeah. Oh, that's fantastic. So then when you came back, there was some question of, you know, what can you bring to the community? Not just how can you do everything they're currently doing, but what else can you bring? Dr. Sarup told me that one of those things he was looking forward to you bringing was transversus abdominis release, which we're planning on doing as our 'How I Do It' today. Let's get to that in a second. Was there anything else like that they said, hey, do you know how to do this or that, and you could bring it to our community?

Dr. Rebekah Wever [00:05:19]: Yeah. So actually, one of the main other procedures that I knew I would really want to be able to do was ERCP. I worked with our advanced GI endoscopists throughout residency as much as I could, you know, but they also had their own expectations and didn't hand over the reins very often, just how they were. I actually got a lot of my experience when I came back here for those two months doing those procedures, and I'm still working with them but getting more to the point of doing them on my own here as well.

Dr. Randy Lehman [00:05:54]: Good. So your group that you joined, how many surgeons are there?

Dr. Rebekah Wever [00:05:57]: There are three others.

Dr. Randy Lehman [00:05:59]: Okay. And they were independent for a long time. I think Dr. Sarup told me they recently became, is it hospital-employed or contracted, or how are they doing it?

Dr. Rebekah Wever [00:06:07]: Yeah, we are hospital-employed now with Ohio Health. And actually, the transition occurred when I signed on.

Dr. Randy Lehman [00:06:16]: So that would have been like three, four years ago?

Dr. Rebekah Wever [00:06:20]: Well, sorry. Signed on like when I actually came in.

Dr. Randy Lehman [00:06:22]: When you started?

Dr. Rebekah Wever [00:06:23]: Yeah, yeah.

Dr. Randy Lehman [00:06:23]: Was it part of that? Now, tell me, go back to second year. Did they give you anything for that commitment? For example, any sign-on bonuses or stipends or income guarantees, anything like that?

Dr. Rebekah Wever [00:06:36]: Yeah, so they did help out with a stipend.

Dr. Randy Lehman [00:06:40]: When you say they. Was it the hospital or was Sarup's group?

Dr. Rebekah Wever [00:06:43]: It was the hospital.

Dr. Randy Lehman [00:06:44]: So you were committed to the hospital, just having a relationship and knowing Dr. Sarup, correct?

Dr. Rebekah Wever [00:06:50]: Yes.

Dr. Randy Lehman [00:06:51]: And you could have come in and basically competed with your mentor, but you did the right thing, and you're all banding together as surgeons. One question we ask every guest is, why is rural surgery special to you? I think there are some obvious things that we could assume. But in your own words, what's so special about what you're able to do right now?

Dr. Rebekah Wever [00:07:11]: Yeah, the main thing for me really is being able to provide care to the community. And, you know, we have a lot of farmers, a lot of people really attached to staying local for their care. My goal is to bring back as many higher complexity procedures that I could so that they wouldn't have to be transferred out. And our patients really appreciate that. They all like to stay local. You know, they want to have their family here with them and not travel so much. So that's been kind of the main thing for me and just being able to help my patients in that way.

Dr. Randy Lehman [00:07:49]: Yeah, for farmers, you know, that's such a career that's so tied to the dirt, to the ground, to that specific spot. Like when you plant crops, you're not going to be anywhere else. Now we have a lot of remote work and more freedom to travel than any time ever. You know, you could have maybe like a shop owner who has a physical location, but farming is special like that. And so I moved back to the family farm that I grew up on, and again, it's really cool and special. I'm just saying all that because you brought up a farmer as the quintessential rural patient that you're taking care of.

Dr. Rebekah Wever [00:08:43]: Absolutely.

Dr. Randy Lehman [00:08:44]: Of course, they want to stay local. So, great. Well, why don't we roll into the "How I do it." We're going to talk about ventral hernia repair, specifically with a transversus abdominis release. The reason I wanted to talk about this is I was talking to Dr. Sarep about you coming, and he said we're really interested in adding that to our practice and looking to you to help do it. Now, my understanding is at this point, you haven't done any in your first eight months, right? Which makes sense. I maybe do one a year. You know, it's got to be the appropriately selected patient, somebody that's not too sick to have an operation in the rural hospital. And it's got to be a ventral hernia that's big enough that justifies a TAR. Do you always do that with a Reeve Stopa retrorectus mesh?

Dr. Rebekah Wever [00:09:43]: Yes. So it's really just an extension of that modified Reeve Stopa from, you know, the original explanation of that procedure. I use a Phasix mesh, different configurations to use, depending on how much you have to mobilize, depending on the hernia that they have.

Dr. Randy Lehman [00:10:02]: So you're putting Phasix in the retroactive space. I'd say a lot of people use a polypropylene plane mesh because it's not being exposed. So tell me about the choice to use Phasix.

Dr. Rebekah Wever [00:10:15]: Yeah. So my attending in residency had a lot of good success with Phasix, and I like that. You know, you have the macroporous and microporous, and this one's a knitted monofilament. So it's pretty well incorporated and it's also shown to not break down in the setting of a bacterial field. Not that, you know, we want any of our patients to get an infection, but that's just an added, let's say, barrier to that dreaded complication.

Dr. Randy Lehman [00:10:51]: Yeah. Antibiotics until the cows come home, and Phasix should not have to be excised, right?

Dr. Rebekah Wever [00:10:56]: Yeah, pretty much. And it gets really well incorporated, so it's kind of a win-win.

Dr. Randy Lehman [00:11:03]: Great. So, to be a little more structured with my introduction into your talk about TAR, why don't we first say who's the patient that's getting it? And to complete that spectrum of hernia, who don't you do in the location where you're at? And then what do you do with the other hernias that aren't candidates for TAR? You see, like the whole spectrum of basically ventral hernia. Maybe starting with size or what other criteria you use to decide those things.

Dr. Rebekah Wever [00:11:36]: Yeah. Like you had previously alluded to, patient selection is key. This is a pretty, obviously big repair, and you don't want to do this on someone who isn't optimized. A lot of my patients, unfortunately, are smoking, smoking packs upon packs a day. So that's first and foremost, I will tell them they have to stop smoking because there's a very high likelihood that they'll have a recurrence or some type of wound complication and maybe a mesh infection if they continue smoking. The other thing is losing weight. I don't believe that my population has a significant issue with this, but it is more pronounced in the patients that come in with these larger ventral hernias. Ideally, they always say BMI of 35, but I've noticed with the few consultations that I've had, it's extremely difficult for them to obtain. We keep working on it, and if there's no higher-risk patients that come in where they're starting to notice some incarceration symptoms or this, that, or the other, we keep working on getting that weight down to an ideal BMI of 35. I would be comfortable maybe going up to a BMI of 40 if they've plateaued out, and other risk factors like smoking, of course, making sure their diabetes is optimally managed. We have a lot of that here as well, unfortunately. So the patients who I wouldn't take to the operating room are those who have one or the other they can't optimize, and then another factor, such as if they've had a loss of domain, those patients really require a little bit more preoperative optimization. In addition to what I previously mentioned in terms of maybe they're a Botox candidate or they need progressive pneumonoperitoneum, which we just don't do here.

Dr. Randy Lehman [00:13:44]: So is there a specific size that you have in mind?

Dr. Rebekah Wever [00:13:49]: Oh, sure. So, you know, I would say not any specific size necessarily. We all know the typical advancements with these types of repairs. You can get up to a 20-centimeter hernia with optimal release of that transverse abdominis. But those were probably better treated by transferring to a larger center where the only thing that surgeon does is hernias. So I would say probably about 15 centimeters would be my maximum.

Dr. Randy Lehman [00:14:32]: How comfortable were you coming out of residency? What were you doing independently, I guess? Expound on that a little bit.

Dr. Rebekah Wever [00:14:40]: Yeah. Wow. So in regards to what we fixed, if I remember correctly, that was more so, you know, our academic residency programs where you might not operate until your fourth or fifth year, and then you're not comfortable operating and would need to go into a fellowship. Well, our program, we got our interns in the operating room pretty quickly. I remember starting on our trauma and acute care service, and I was in the operating room doing a gallbladder within that first month. Great senior residents, great attendings. Then you just build on that, and getting your residents into the operating room sooner really excels the process of getting them ready for practice. That was their whole goal. So it was a great model. I did quite a number of procedures independently. Shoot, I was even a third year for a lot of the cases. You know, the more standard ones, your breasts, your appendectomies, your gallbladders, of course, not the very complex gallbladders. But by the time I was into the fifth year, speaking back to Dr. Matt Sorrell, he would let me go in and start these open retrorectus cases, and he'd come in later, which gave you a huge amount of confidence and feeling like you were ready to do these cases and also helped you learn what you weren't sure on. That back in the second year of residency, we were able to go to a rural site, and those attendings would also just let you go. It'd be based on their confidence level in you, of course. Let me think back to specific cases. Our attendings did a lot of robotics and then tried to focus on hernias. I'd be doing most of those cases on my own, starting at the middle of the fourth year or so. You know, more standard robotic hernia cases, or the attending would just be there retracting and let you do your own thing, even starting third year.

Dr. Randy Lehman [00:17:04]: So, by the time you're a chief and you're doing a retrorectus with a TAR, did you incise laterally before the attending was in the room?

Dr. Rebekah Wever [00:17:18]: No. So he would be doing one side, I'd be doing the other side.

Dr. Randy Lehman [00:17:21]: But you would get the hernia sac all dissected free and get the retrorectus space completely freed up.

Dr. Rebekah Wever [00:17:28]: So before he came into the retrorectus space, he'd be in there by that time. I definitely took my time freeing up adhesions and taking down the hernia sac. A lot of these patients had a significant amount of intra-abdominal adhesions. And so just that he gave me that time to do that was important.

Dr. Randy Lehman [00:17:48]: Do you enter the abdomen on all these cases?

Dr. Rebekah Wever [00:17:51]: Yes.

Dr. Randy Lehman [00:17:52]: Okay, so in terms of maintaining the sac and pushing it down and then going to the side and just staying outside of the peritoneum, you've never done that before?

Dr. Rebekah Wever [00:18:06]: What do you mean?

Dr. Randy Lehman [00:18:07]: Sorry, like I'm saying if you can keep the sac intact. Like for me, if you're doing a TAR or, I mean, if you're doing a Reef-Stoppa, you don't have to free any abdominal adhesions because you're just trying to get the sac back in, get the posterior sheath back together, and put your mesh there. But did you guys do a full enterolysis for all of them?

Dr. Rebekah Wever [00:18:31]: Yeah, at least all the ones that I was involved in. Mostly because it does help decrease the tension on your flap to be able to pull that together. It could have potentially helped us do less dissection and maybe even avoided a TAR in some of those cases where we just did a Reef-Stoppa.

Dr. Randy Lehman [00:18:48]: Yeah, that makes sense. I mean, you have to see where you're throwing your stitches to get your posterior sheath closed. So you have to do some...

Dr. Rebekah Wever [00:18:55]: Yeah.

Dr. Randy Lehman [00:18:55]: Okay, fair enough. And then when you came out of residency, so basically you were... When you had to do some credentialing process, I assume, did they require some sort of proctorship, like a certain number of cases for you to be doing with somebody else watching you when you first started for your hospital privileges?

Dr. Rebekah Wever [00:19:20]: There weren't any specific requirements that I was aware of. I would more so actually just scrub in with my colleagues as much as I could. Not that they were coming into any of my cases. Even now, with certain ones that, like I mentioned before, the ERC, I hadn't done as many as I would have liked in residency, and so we're doing that type of proctorship throughout those cases.

Dr. Randy Lehman [00:19:54]: Is it structured like you're turning in the cases as you do them?

Dr. Rebekah Wever [00:19:59]: I'm keeping a log of the cases that I've done, and those have mostly been with Dr. Sarap.

Dr. Randy Lehman [00:20:06]: Did somebody ask you to do that, like the credentialing committee?

Dr. Rebekah Wever [00:20:10]: No, this was kind of just a combined decision between Dr. Sarap and myself because, again, you want to be able to know your limitations when you come out of residency. If I had felt unsure of any particular case, I would just ask them to come in with me to help out.

Dr. Randy Lehman [00:20:30]: Yeah. So what was the first case that you did out of residency?

Dr. Rebekah Wever [00:20:36]: So my first case out of residency, I started on call that weekend, and I had an acute abdomen that came in. They called me right away. I was like, well, there are a number of things that could be happening based on your symptoms and your exam. We just need to get to the operating room. You're septic. I don't need a CT scan to tell me what to do. So we went into the operating room and ex lap'd him. Found a perforated prepyloric gastric ulcer. So that was quite the case. Newly diagnosed cirrhotic with ascites as well.

Dr. Randy Lehman [00:21:18]: Oh, my.

Dr. Rebekah Wever [00:21:19]: That was great.

Dr. Randy Lehman [00:21:20]: So did you call somebody to come help you with that?

Dr. Rebekah Wever [00:21:23]: I did. So that being the first case, going in not knowing what was going to happen, I had one tech. I was like, yeah, I want to get this guy off the table as quickly as possible. And not only have, you know, second set of opinions and everything. I did call Dr. Sarap.

Dr. Randy Lehman [00:21:37]: And you went with no CT?

Dr. Rebekah Wever [00:21:39]: Correct.

Dr. Randy Lehman [00:21:40]: Ha. But it wasn't mandatory that somebody was with you?

Dr. Rebekah Wever [00:21:49]: No.

Dr. Randy Lehman [00:21:50]: You just called and, you know, how long do you take, like a week of call at a time or how did you call?

Dr. Rebekah Wever [00:21:56]: We do call one in four, so it's been great. I'm on call with my operating day, which is on Monday now. And then that being said, when I'm on call on the weekend, which is, we take Friday through Sunday, well, through Monday morning technically. I'll just have Friday morning to Tuesday morning when it's my weekend, and that's every fourth weekend. That's a sweet setup.

Dr. Randy Lehman [00:22:17]: So did you know you already talked to Dr. Sarap ahead of time for your first day on call and, like, say, hey, if I need you?

Dr. Rebekah Wever [00:22:28]: Oh, absolutely.

Dr. Randy Lehman [00:22:29]: You knew he was in town.

Dr. Rebekah Wever [00:22:31]: Yes, I know who's in town every weekend with me.

Dr. Randy Lehman [00:22:36]: Yeah, that's fair. Good. I'm just kind of thinking in my own experience as you're talking. That's why I'm like in my own head over here. So don't worry about it. It sounds like you have a great setup, and it sounds like such a great group that they've just really allowed you to come out swinging and knock out a case like that. So that patient, what kind of operation did you give them? I'm just curious.

Dr. Rebekah Wever [00:23:03]: Yeah, a modified Graham patch repair. Luckily enough, and it was interesting, I believe that he had been perforated for a while, but his ascites had actually created a more favorable environment. Absolutely. So, he had really good tissue around this ulcer, so I reapproximated that and then brought up a patch of omentum.

Dr. Randy Lehman [00:23:27]: Yeah, so what did you use to close the hole?

Dr. Rebekah Wever [00:23:30]: So I actually just used some Ethibond.

Dr. Randy Lehman [00:23:34]: Did you debride the edges a little bit?

Dr. Rebekah Wever [00:23:36]: Yeah, he didn't need much, though. Again, that tissue looked pretty well.

Dr. Randy Lehman [00:23:40]: And so, like, how many stitches approximately did it take?

Dr. Rebekah Wever [00:23:44]: Shoot. I'm trying to think back. I think I put in about four.

Dr. Randy Lehman [00:23:50]: And you did a transverse closure?

Dr. Rebekah Wever [00:23:52]: Yes.

Dr. Randy Lehman [00:23:53]: And it's just a through-and-through stitch, or was it some sort of Lembert stitch?

Dr. Rebekah Wever [00:23:58]: No, it was through-and-through.

Dr. Randy Lehman [00:24:01]: And, you know, Graham's patch has been described different ways, and I've seen it different ways, but one way to do it is to leave the long tails on and then bring your pedicle tongue of omentum up and lay it on top and then stitch down with, like, that knot staying there. The other way would be, like, if you just did some bites on either side and stitched your tongue up. Is that how you did the tongue of omentum?

Dr. Rebekah Wever [00:24:27]: Yeah. So after your primary repair of that, you get a little further out on either side. You take your stitch through one of those sides and then through the omentum, actually. And then on the other side as well.

Dr. Randy Lehman [00:24:39]: Yeah. And I've also seen it where we go through the omentum or not through the omentum, but that's exactly how I'd like to do it. Now, did you do that with a Vicryl or with a permanent stitch as well?

Dr. Rebekah Wever [00:24:48]: So that one was with a Vicryl 3-0. Yes. Yes.

Dr. Randy Lehman [00:24:52]: It was cool, man. Great case. If you had it to do over again, would you do it open?

Dr. Rebekah Wever [00:24:58]: Yes, I would.

Dr. Randy Lehman [00:24:59]: In those circumstances, you'd stick a scope in?

Dr. Rebekah Wever [00:25:01]: No, not in that particular patient. Again, he was septic and, you know, undifferentiated. I was pretty confident it was a perforated gastric ulcer. Just again, his symptoms and his exam and history. But again, undifferentiated. You just want to get in there, get the patient off the table as quickly as possible.

Dr. Randy Lehman [00:25:20]: Wow. Yeah, I would say they fix the five in South Dakota. If you're doing that day one and without a CT and then just nailing it, knocking it out of the park like that. That's awesome. Have you seen this guy back?

Dr. Rebekah Wever [00:25:32]: Yeah, he's doing great.

Dr. Randy Lehman [00:25:34]: Still alive?

Dr. Rebekah Wever [00:25:35]: Yeah. Absolutely amazing. This was actually a pretty eye-opening experience for him. And a lot of our patients here don't keep up with their primary care physician. So I was his primary care physician for a while, trying to get him better optimized and everything. But that was.

Dr. Randy Lehman [00:25:55]: So he stopped smoking and drinking and.

Dr. Rebekah Wever [00:25:57]: Yeah, he.

Dr. Randy Lehman [00:25:58]: He got baptized and now he's good to go. All right, that's awesome. Well, that's just such a cool story. And we need to get back to TAR. So say it's this patient and he comes back with this huge ventral hernia later.

Dr. Rebekah Wever [00:26:12]: Yeah.

Dr. Randy Lehman [00:26:13]: What? Let me go to the other extreme first and say you got a 1cm umbilical hernia. You're not doing a TAR for that?

Dr. Rebekah Wever [00:26:21]: No.

Dr. Randy Lehman [00:26:22]: Right. So at what size do you place mesh? At what size do you do the retrorectus? And then how do you decide who needs the TAR?

Dr. Rebekah Wever [00:26:35]: Okay, first things first. So when to place a mesh, you know, it's a lot of patient factors too, that you want to think about. But in terms of specific hernia size, you know, one to two centimeters, you know, the recommendation against is two, but you have a lot of patient factors to weigh in on that. And then when to do the retrorectus, those are usually going to be those patients that come in, a lot of them that I've seen, you know, incisional hernias, they're gosh, you know, upwards, greater than 5cm. If you can pull them back primarily, great, and place a mesh. But you always have to just counsel the patient on, you know, all the possibilities. So that's kind of how I go about that. It's not that, you know, every hernia this size is going to get repaired with a mesh or get a retrorectus. So I just say, ideally we do this, but if I have to, I can have these other options on the table.

Dr. Randy Lehman [00:27:36]: Do you have a robot down there?

Dr. Rebekah Wever [00:27:38]: We do not. We are currently working on it. And last we discussed it with Ohio Health, it was on the budget.

Dr. Randy Lehman [00:27:46]: Okay, well, do you think that you're doing your patients a disservice by not having a robot specifically for ventral hernia?

Dr. Rebekah Wever [00:27:55]: Not necessarily. So now would it be nicer? Potentially. However, in terms of the repair? No. What I do for ventral hernia repairs, they're just, you know, standard. I do an open primary closure. So, you know, let's say umbilical hernia, I'll dissect that out, place my sutures, and then go in laparoscopically and place a larger mesh. So I believe the repair is just as good as robotic.

Dr. Randy Lehman [00:28:24]: Yeah. What kind of mesh are you using there?

Dr. Rebekah Wever [00:28:26]: So that'd be also a Phasix mesh.

Dr. Randy Lehman [00:28:28]: Okay. Do you use any permanent mesh for ventral hernias ever?

Dr. Rebekah Wever [00:28:37]: No. And that's again, you know, our supplies here. We do the ST Echo for those ventral hernias, Phasix.

Dr. Randy Lehman [00:28:46]: ST Echo is what you're using?

Dr. Rebekah Wever [00:28:48]: Yep.

Dr. Randy Lehman [00:28:49]: And that's like either a circle or an oval shape?

Dr. Rebekah Wever [00:28:53]: Yeah, we have the circle shapes here. We have two different sizes.

Dr. Randy Lehman [00:28:57]: Okay, like an 11 and a 15 or do you have bigger than that?

Dr. Rebekah Wever [00:29:01]: Oh, no, not bigger than that. No.

Dr. Randy Lehman [00:29:03]: Okay, sweet. So then we get to a point where on this particular patient, you're saying that's not a good option for you because I think your hernia is big enough and we are going to want to put a retrorectus, and we're going to have to have the extra reach. Now I've. How much extra reach do you think you really get with the TAR on each side?

Dr. Rebekah Wever [00:29:23]: On each side. So let's see. Probably a good 10cm maybe if you're really releasing the entirety of that transverse abdominis.

Dr. Randy Lehman [00:29:41]: Okay, that's a pretty good, you know, reach. Then you're saying you could bridge a 20cm defect by a bilateral TAR.

Dr. Rebekah Wever [00:29:48]: Theoretically. So that's.

Dr. Randy Lehman [00:29:49]: I agree. Theoretically, yeah.

Dr. Rebekah Wever [00:29:51]: Yeah. So that's what, you know, all the literature says. By no means have I had to do that extensive of a dissection. But again, in all the readings and the articles, they're like, you can get up to 10cm each.

Dr. Randy Lehman [00:30:04]: What do you think in residency was the biggest hernia actually fixed using this technique just by memory and that was a time of your life where you're trying to black out, so I get it.

Dr. Rebekah Wever [00:30:17]: Oh, very true. But try to think back, you know, probably 10cm at least on the ones that I've done in terms of.

Dr. Randy Lehman [00:30:27]: Transverse defect, and then maybe it's 15 top to bottom or something. Yeah. So say you have a patient like that. All right, I think our. We've gone, we've waxed eloquently, and we probably need to jump ahead. Our discerning listener knows how to make an incision, get down, dissect the sac free. Maybe they freed all that. You freed all the intra-abdominal adhesions. You've excised a portion of your sac. You've done a retrorectus dissection bilaterally. Okay. Everybody knows how to do that. Now, how do you do the TAR?

Dr. Rebekah Wever [00:30:59]: Sure. So the important thing is you completely dissect out your retroactive space. You have the arcuate line, and that's going to really help identify your incision for the TAR. It's going to be, again, you know, 1cm medial to your perforators. If you see that arcuate line, you can get your tonsil, Kelly, whatever you want to use through there and dissect that plane before you cut, which is a huge, important step to make sure that you're getting into the space. The first time through residency, you kind of learn your little key steps and whatnot, of course, but that's kind of how I would start doing that. If you want to look at it more cranially, you have those transversus abdominis fibers that you can see coming through that area as well.

Dr. Randy Lehman [00:31:54]: So, okay, so you start caudally, however.

Dr. Rebekah Wever [00:32:00]: Yeah, with that arcuate line and developing that.

Dr. Randy Lehman [00:32:05]: And you're talking about the arcuate line, not the semilunar line, correct.

Dr. Rebekah Wever [00:32:09]: Yeah.

Dr. Randy Lehman [00:32:09]: And so you jump on. So you got cokers on your fascia, and you're pulling it towards you.

Dr. Rebekah Wever [00:32:15]: Right.

Dr. Randy Lehman [00:32:15]: And then you're inferior, and you see your arcuate line, and you go below the arcuate line. And where exactly do you put your tonsil?

Dr. Rebekah Wever [00:32:21]: So you're going to develop that plane, and you want to be 1 cm medial to those perforators.

Dr. Randy Lehman [00:32:27]: Okay. And then as you... Do you have any tips or tricks on how to identify the perforators?

Dr. Rebekah Wever [00:32:35]: Oh, it's again, just making sure that your retrorectus dissection is complete because those are your lateral point of your dissection. So taking it slow, doing quant dissection, cautery when you need to. And again when you're getting out to that aspect, just be cognizant that they're coming up pretty much.

Dr. Randy Lehman [00:32:57]: Okay. And then as you are approaching, how do you do the rest of like going from? You go all the way from the bottom to the top generally like a...

Dr. Rebekah Wever [00:33:07]: Zipper then technically, now a lot of times it's really just what the patient planes are giving you. Right. They're more difficult caudally, then you go somewhere else. And then the rest of it will show itself to you as long as you do what's easy first.

Dr. Randy Lehman [00:33:26]: And so then the first thing you see after you incise the fascia, you see the transversus muscle fibers.

Dr. Rebekah Wever [00:33:33]: So yeah, you should be able to see those and those should be pushed upward.

Dr. Randy Lehman [00:33:39]: Like upward. You mean up and lateral right away.

Dr. Rebekah Wever [00:33:42]: Up, away from your fascia.

Dr. Randy Lehman [00:33:46]: Okay. And then you're dividing that muscle fiber like between a clamp with like a little Parkinsonian trimmer. Any other specific little tips like that?

Dr. Rebekah Wever [00:34:00]: So taking it slow, you know, again with your instrument, Kelly or whatever you want to use to develop that plane with those muscle fibers.

Dr. Randy Lehman [00:34:12]: Okay.

Dr. Rebekah Wever [00:34:12]: Going slowly with that again, just decreasing your bleeding and everything.

Dr. Randy Lehman [00:34:18]: Yeah. So you work that all the way from top to bottom, and then your mesh is going to go out into this plane like underneath the cut transversus abdominis muscle. How far out are you placing your mesh? What size of mesh are you going to be using?

Dr. Rebekah Wever [00:34:39]: So the mesh for me ideally will just coat the entirety of my dissection, however far out we need to mobilize to get, you know, that tension-free closure of the posterior and anterior rectal sheath. So shoot largest one. I mean sometimes you have to use two meshes actually, and you can do if the standard square because again, you're going to have more of an elliptical space. You can, you know, just angle the mesh in a diamond shape looking at the patient straight on.

Dr. Randy Lehman [00:35:20]: Or you can cut the corners off.

Dr. Rebekah Wever [00:35:22]: Yeah. Or you can use kind of a... I've heard it explained as like a baseball diamond where you place the mesh in a diamond shape, and then you use another square or a rectangle, whatever fits that more cranial aspect of your dissection.

Dr. Randy Lehman [00:35:42]: Okay, very good. So how do you secure the mesh then?

Dr. Rebekah Wever [00:35:46]: We had PDS and you would do a few lateral. But then you would also secure it to your posterior rectus closure along the midline.

Dr. Randy Lehman [00:36:00]: Okay, and I didn't ask this but you closed your fascia with what?

Dr. Rebekah Wever [00:36:05]: So that was with two 0-PDS.

Dr. Randy Lehman [00:36:07]: Two 0-PDS. Okay, so you're gonna throw a few stitches to secure the mesh just kind of around.

Dr. Rebekah Wever [00:36:15]: Yeah. Laterally. You want to, of course, make sure that the mesh is laying flat and then down the midline of your posterior rectus closure.

Dr. Randy Lehman [00:36:23]: All right. And then you're always getting the anterior rectus closed over the top of this.

Dr. Rebekah Wever [00:36:29]: I've not had any issues with that. Again, however, I've not had any issues with closing the posterior rectus sheath either.

Dr. Randy Lehman [00:36:37]: Yeah. So then you're closing that with the two 0-PDS as well.

Dr. Rebekah Wever [00:36:42]: Yeah. Kind of depends on the tissue. You can use a 2O or an O. Huh.

Dr. Randy Lehman [00:36:46]: And you like these O single strand, or...

Dr. Rebekah Wever [00:36:50]: I do. I use the O single strand.

Dr. Randy Lehman [00:36:51]: And that's running.

Dr. Rebekah Wever [00:36:52]: Yep.

Dr. Randy Lehman [00:36:53]: Okay. You throw a stitch at each end and then tie it in the middle or... Okay. Okay. And you're leaving drains for this?

Dr. Rebekah Wever [00:37:01]: I do. I leave a drain in that retrorectus space above the mesh, and then again subcuticular.

Dr. Randy Lehman [00:37:07]: Okay. So your first one comes out to one side. You know where it is. The other one comes out to the other side. So you know where it is.

Dr. Rebekah Wever [00:37:14]: Always. Always. You know, the retrorectus space coming on the right because rnr and then...

Dr. Randy Lehman [00:37:18]: Rnr.

Dr. Rebekah Wever [00:37:19]: Yeah.

Dr. Randy Lehman [00:37:20]: And you just kind of coil it over the top. Or... Or...

Dr. Rebekah Wever [00:37:23]: Yeah. So there's gonna be two drains in each space, and one is gonna go along the right gutter and the ones that are gonna be on the left.

Dr. Randy Lehman [00:37:32]: Okay. So four total drains or three total drains.

Dr. Rebekah Wever [00:37:36]: You know, if the subcutaneous space is amenable to one drain, that's fine. But... Okay, in that retrorectus space.

Dr. Randy Lehman [00:37:43]: Okay, those are 19 French round JPs, or what do you use?

Dr. Rebekah Wever [00:37:49]: Yeah, those are JP drains.

Dr. Randy Lehman [00:37:51]: Okay. I'd like to jump ahead to our... Usually our last segment, which is resources for the busy rural surgeon. Because I want to ask, is there any resource, like your first tar that you go to do? Are you just gonna list it and you're just gonna go. Or is there anywhere you're gonna go to, like, freshen up and, like, a video resource or anything of that nature that you could share with us?

Dr. Rebekah Wever [00:38:16]: Yeah, I mean, nothing necessarily in particular. There is a book, however, that I would recommend, and it's going to be the Hernia Surgery. I think it's Current Principles. Shoot, I'm blanking on the... Oh, Novitsky. That's what it was. That book I would again, just brush up on and, you know, reach out to my attending from residency, just say, hey, you know, have you changed anything? You know, what have you found to be more beneficial, you know, again, from when I was training, because everything changes, constant change nowadays. And so reach out to him, just make sure there's been nothing new that he's found that worked for him and go from there. I would definitely ask one of my partners to be in on these cases as well. You mentioned that aspect of my career earlier, so.

Dr. Randy Lehman [00:39:22]: All right, wonderful. Well, let's move on to the next segment of the show then, which is the financial tips. So did you have student debt at any point or do you still.

Dr. Rebekah Wever [00:39:34]: Yeah, I do, but a lot of it, you know, my family did help tremendously. So it's a balance of, you know, interest rates on that versus the home versus long term. What's gonna be the best to pay off sooner? Obviously, you want to focus on retirement, so it's all balance.

Dr. Randy Lehman [00:39:52]: You're not planning on the public student loan forgiveness program, are you?

Dr. Rebekah Wever [00:39:57]: No, I don't necessarily qualify.

Dr. Randy Lehman [00:40:00]: Yeah, that's fair. Tell me a little bit more about signing your contract early. So you're a second-year resident.

Dr. Rebekah Wever [00:40:12]: Yeah. So this was before Ohio Health, and so I got a new contract with Ohio Health.

Dr. Randy Lehman [00:40:18]: Okay. But they assumed all of the terms of the initial contract?

Dr. Rebekah Wever [00:40:23]: Well, we had a new contract actually with Ohio Health.

Dr. Randy Lehman [00:40:27]: So by the hospital. Was the hospital independent before that?

Dr. Rebekah Wever [00:40:31]: Yes, as far as I understand.

Dr. Randy Lehman [00:40:34]: Okay. And then by the hospital, you did sign a contract with that original hospital. What was it called?

Dr. Rebekah Wever [00:40:40]: It was more so just an agreement to come and practice there after residency. I didn't have any major stipulations that I'm aware of. I mean, maybe they said something about working for a certain number of years, but my new contract with Ohio Health was purely their contract. They like to do things their own way.

Dr. Randy Lehman [00:41:04]: Okay, well, with that initial contract, was it like you just have to come here and work generally in this area? You could work for yourself and bill on your own. Or was it like, no, you're working for the hospital, we're billing for you, you're on call a certain amount of time?

Dr. Rebekah Wever [00:41:19]: And it was more so that I would come and join this independent group here, but work through their hospital.

Dr. Randy Lehman [00:41:27]: Okay. Do you mind sharing any details of that? You don't have to.

Dr. Rebekah Wever [00:41:35]: There weren't really many. I guess it was still pretty early in the stages and we were going to revamp it a little bit more, but with the group becoming hospital-employed, there was no reason.

Dr. Randy Lehman [00:41:47]: Yeah. But what they were willing to give you was a monthly stipend of a certain amount of money?

Dr. Rebekah Wever [00:41:55]: Yes.

Dr. Randy Lehman [00:41:56]: For that commitment to come work there.

Dr. Rebekah Wever [00:41:59]: Yeah, pretty much.

Dr. Randy Lehman [00:42:00]: Do you have something for that classic rural surgery story? I mean, you kind of already did with your perforated ulcer. Did you have anything else that you want to tell a story about?

Dr. Rebekah Wever [00:42:11]: So the only other one that really sticks out to me was an elderly gentleman, frail, malnourished. He had just had a CABG three weeks ago and came into our emergency room. I get called at midnight, classic. They tell me, oh, yeah, it looks like a concerning hernia. I go in and evaluate him, and unfortunately, he has gangrene of the skin overlying this right inguinal hernia. So it's obviously been out for quite some time, and he let it go. There was also an underlying abscess. So we took him in the middle of the night. Obviously, you don't want to sit on that. I did this through a groin incision, trying to keep the contamination within the groin and outside of the abdominal cavity. We got pretty lucky. We didn't even have to release much of the pelvic floor to be able to resect it. We had to resect the terminal ileum and the first part of the cecum. We were able to do that anastomosis through that inguinal incision.

Dr. Randy Lehman [00:43:29]: Okay.

Dr. Rebekah Wever [00:43:30]: We left him open, kept him in the hospital for a few days. Once it appeared that the infection had cleared up and the dead tissue demarcated itself better, I took him back to the operating room, debrided that extra dead tissue, closed him, left a drain and everything. But, yeah, I was pretty worried about him, mostly with his recent CABG and his underlying medical conditions.

Dr. Randy Lehman [00:43:58]: Oh, he's fixed. Yeah, with the CABG, you know.

Dr. Rebekah Wever [00:44:02]: Yeah. Good to go.

Dr. Randy Lehman [00:44:03]: All right, so that was an indirect hernia, and it's obviously right.

Dr. Rebekah Wever [00:44:10]: Yep.

Dr. Randy Lehman [00:44:10]: The perforation, was it in the ileum or in the cecum?

Dr. Rebekah Wever [00:44:15]: That was in the cecum.

Dr. Randy Lehman [00:44:17]: And so you had stool in your wound with an abscess that had been festering?

Dr. Rebekah Wever [00:44:21]: Yep. Yep, all of it.

Dr. Randy Lehman [00:44:23]: Wow. So, did you resect the testicle?

Dr. Rebekah Wever [00:44:27]: Yes, it had pretty much depleted and strangulated the testicle's blood supply, so it wasn't really viable either.

Dr. Randy Lehman [00:44:35]: So you did the orchiectomy. Your hole that you're looking at was like, what, three centimeters or so, something that you could get an anastomosis back through?

Dr. Rebekah Wever [00:44:44]: Exactly. Yeah.

Dr. Randy Lehman [00:44:45]: And when you did your anastomosis, it was a side-to-side stapled anastomosis?

Dr. Rebekah Wever [00:44:52]: Yeah, stapled.

Dr. Randy Lehman [00:44:54]: Okay. You were able to kind of milk it back through, no problems. Did you do any over-stitching? Did you do the crotch stitch or anything like that over the staple line?

Dr. Rebekah Wever [00:45:03]: Yeah, we did the typical side-to-side staple anastomosis. I didn't oversew the staple line. I've never done that with any of my stapled anastomoses.

Dr. Randy Lehman [00:45:13]: Okay. Yeah, great. And you kept saying we, so I assume you called a partner in for that one. How far into practice were you, like, how many months?

Dr. Rebekah Wever [00:45:20]: Oh, shoot. That was probably four months in, if I had to guess. Yeah.

Dr. Randy Lehman [00:45:27]: Yeah. I just have one last question for you. In your residency, how many cases did you do?

Dr. Rebekah Wever [00:45:31]: How many cases total? Like, total? I was at 1500 total major cases.

Dr. Randy Lehman [00:45:38]: Well, thank you so much, Dr. Wever, for joining us on this episode of The Rural American Surgeon. It's really been a pleasure to have you.

Dr. Rebekah Wever [00:45:43]: It's been a pleasure. Thank you, Randy.

Dr. Randy Lehman [00:45:45]: And for the listener, thank you for joining us today. We really appreciate you being here. Thank you for giving us those ratings and reviews; that helps us on our overall algorithm for Spotify and Apple Podcasts. Please don't forget to tell all your friends about it. You know, share some of the posts. That really helps us get the message out to the affected audience, which is really a small but niche group of people, which is The Rural Surgeon. We just appreciate you having us in your earbuds today. And we will see you on the next episode of The Rural American Surgeon. Thank you.