Episode 5

Mastering the Right Colectomy with Dr. Chris Huiras

Episode Transcript

Dr. Randy Lehman: [00:00:07] Welcome to the Rural American Surgeon. I'm your host, Dr. Randy Lehman. On this show, you'll receive powerful insights and resources for rural surgeons. I'm a general surgeon in northwest Indiana, and this show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics ranging from practical surgical tips to a host of others, including rural lifestyle, finance, training, practice models, and more. We'll have a segment called Classic Rural Surgery Stories, where you'll get a feel for how practice in the country differs from the city. Whether you're a surgeon, other specialist, or primary care provider, or simply someone interested in healthcare for rural America, I'm glad you're here. Now, let's get into the show.

Dr. Randy Lehman: [00:00:46] Welcome back to another episode of the Rural American Surgeon. I'm here with Dr. Chris Huiras, General Surgeon from La Crosse, Wisconsin, who was very instrumental in training me. I'm so glad that you came today. So, thanks for joining us.

Dr. Chris Huiras: [00:00:59] Thank you very much, Dr. Lehman, for the invitation. It's always a pleasure.

Dr. Randy Lehman: [00:01:03] We're going to start with an introduction about you, so you can tell us maybe a little bit about your training, where you're from, and then what your practice looked like through the years.

Dr. Chris Huiras: [00:01:11] Sure. My family is from Minnesota, but we moved to Madison, Wisconsin, when I was young. That's where I went to high school, college, and medical school. I did some of my residency training there as well.

When I came to La Crosse, Wisconsin, initially to do family medicine residency, I loved surgery, but I also loved pediatrics and OB. The spectrum of family medicine really appealed to me, but surgery got the best of me. During my training in family medicine, I did my first year of family medicine training and really got bitten by the surgery bug, primarily because of one of the junior staff who had just joined the practice.

Dr. Gordon Cusick, or Gordy, came from St. Paul at the same time that I started my residency, and we hit it off. He must have really enjoyed being with house staff and anyone, as opposed to the older surgical staff at the time. We got to be good friends, and he would invite me to help him on surgical cases as an assistant, even when I wasn’t on a surgical rotation. After the first year, I really got bitten by the bug of surgery. I was most relaxed, happiest, and energized when I was on surgical rotation.

So, I wrote to some surgical residencies, actually thinking about changing specialties. I lived in La Crosse, Wisconsin. My last name looks foreign, and I got responses from a few programs saying, “We have more than enough qualified US graduates, so we don’t accept foreign medical graduates.” So, I shelved the idea for a year.

But in the course of the next year, Dr. Cusick and I spent a lot of time together, and it really burned inside me. I applied for residencies and started my application process by applying to the Gundersen Clinic, which had a small program at the time with a limited number of residents per year. The timing was really uncanny—probably supernatural.

I interviewed for the residency on a Friday, and on Sunday, one of the first years was up all night on call at the hospital and quit on Monday. So, I had just interviewed, and they offered me a position. I ended up having the world’s longest internship: two years of family medicine training, which taught me a lot of basic medicine, and then five years in surgical residency.

During my training, the local M and M conferences, staff conferences, and other events allowed Gordy and the other partners to observe and mentor me.

And Gordy asked me to come back and join him in practice at the beginning of my fourth year, which was a real treat for me. It was a real honor. I completed my training and joined Dr. Cusick and the rest of the group at the other hospital in La Crosse. Unfortunately, Gordy developed stage four colon cancer in his 40s, with no family history or risk factors. It was a very traumatic time to lose a friend.

Gordy was truly my inspiration. He taught me a lot, was a friend, a colleague, and a neighbor. He had a no-nonsense approach as a surgeon but was gentle and could communicate with anyone—from the Mayo Board of Governors to holding my newborn son. His wife and daughters are lovely people, and I miss him dearly. I think about him often, and he was instrumental in guiding me back into a career in surgery.

I have just spent over 30 years at Mayo, and Dr. Lehman, among others, has rotated with us as a resident. Watching the next generation learn, ask questions, and grow has been inspirational for me as well.

Dr. Randy Lehman: [00:05:47] Thank you. In your practice at La Crosse, that’s a referral center of its own, correct? But you’ve also practiced in critical access settings through the Mayo Clinic Health System. So, you have this unique perspective. The next segment is the question: Why is rural surgery important to you?

I’d like to share a quote from Dr. Cusick that I’ve told dozens of times to others: “In surgery, you can do Cesarean sections or carotids, but not both.” That’s a classic example of the spectrum of general surgery. Some may include vascular procedures—Whipple procedures, liver resections, esophagectomies—those are the highest-level general surgery cases. Or you may have a rural practice where you’re doing scopes, some GYN surgeries like hysterectomies or tubal ligations, or procedures like vasectomies, carpal tunnels, or Cesarean sections.

In rural settings, you might not have an ICU, so you’re not doing carotids or Whipple procedures. Could you talk about the differences between these two practices and how they’ve shaped your career?

Dr. Chris Huiras: [00:07:08] You bet. First of all, my training program emphasized preparation for rural practice. We gained experience in ENT, GYN, urology, and even took orthopedics calls. The program was originally designed to train surgeons for rural environments, but it also prepared us for specialty training. Some colleagues went on to colorectal or cardiac surgery.

Our residency exposed us to a broad spectrum of the surgeries you described. Interestingly, we were a referral center but also referred patients elsewhere. During my practice, we partnered with the Mayo Clinic and became part of the Mayo Clinic Health System, which expanded what we could offer.

When I started, like most general surgery residents, I was eager to perform Whipple procedures, esophagectomies, and lung resections. Those cases were part of my practice for about the first 10 years. However, as specialties evolved and diagnostics advanced—for example, endoscopic ultrasound for staging esophageal or pancreatic cancer—we no longer had access to certain cases.

Dr. Chris Huiras: So, we leaned on the diagnostics in Rochester, but the patients wouldn’t always come back to us for their surgery. Contrast that with our need to support two rural hospitals in western Wisconsin. We had clinics in both Tomah, Wisconsin, and Sparta, Wisconsin, with one surgeon covering both locations.

In the early 2000s, during the Gulf War, the surgeon was a reservist and was called up just after our department signed a contract with the VA system to provide colonoscopies. Suddenly, we had a contract but no surgeon to service it. Leadership approached me because I had an interest in endoscopy, asking if I’d be willing to cover it. I jumped at the chance. I always tried to make endoscopy part of my practice—pre-op for hernias, post-op for colon resections, and more. This was a natural extension of what I was already doing.

It was a different world. Even though it was only a 26-mile trip, it felt like 150 miles. The county was much poorer than average for Wisconsin, and the patient population had fewer resources. Many patients lacked healthcare awareness or neglected their health. Some didn’t have transportation to reach La Crosse and would walk to their hospital appointments or procedures. Providing personal care to such a population and making a huge difference in their lives was deeply satisfying as a rural practitioner.

Dr. Randy Lehman: [00:10:39] Yeah, I think I’m nodding my head because I can relate to a lot of those things. Let’s move on to the next segment of our show, called "How I Do It." This time, we’re going to talk about right colectomies. So first off, why would you perform a right colectomy for someone?

Dr. Chris Huiras: [00:10:58] Typically, a right colectomy is done for tumors or cancer. In the world of endoscopy, there are often polyps that can’t be removed or have concerning pathology, even if they’re not frank cancers. So, it’s primarily performed for neoplasms.

Dr. Randy Lehman: [00:11:19] So, it’s mostly cancer. You’re looking for your lymph node harvest. When you bring the patient to the operating room, do you place them under general anesthesia in a supine position? Do you tuck the arms?

Dr. Chris Huiras: [00:11:29] I tuck both arms.

Dr. Randy Lehman: [00:11:30] Tuck both arms. Do you do anything else pre-anesthesia or before going into the operating room?

Dr. Chris Huiras: [00:11:38] Patients have a Foley catheter and SCDs—or thrombo guards, as some call them. For a right colon procedure, you don’t generally need to get into the pelvis, so a plain supine position is perfect.

Dr. Randy Lehman: [00:11:54] Do you use an orogastric (OG) tube or nasogastric (NG) tube?

Dr. Chris Huiras: [00:11:56] I leave that to anesthesia. Early in my training, every colon resection patient had an NG tube that stayed in until they passed flatus—five to seven days post-op—and remained in the hospital the entire time. I quickly moved away from that practice. I ensure anesthesia is satisfied with their NPO status, and if they need to decompress the stomach, they handle it. But I don’t routinely place an NG tube for a right colon.

Dr. Randy Lehman: [00:12:25] Do you use any kind of special abdominal wall blocks?

Dr. Chris Huiras: [00:12:31] As my practice evolved, the TAP block became a great tool. Either anesthesia or I would place it, and it’s fantastic.

Dr. Randy Lehman: [00:12:40] Do you usually place those pre-op or post-op?

Dr. Chris Huiras: [00:12:42] Post-op.

Dr. Randy Lehman: [00:12:43] Sounds good. I had—what was it? Another question.

Dr. Chris Huiras: [00:12:47] Prep a standard abdominal.

Dr. Randy Lehman: [00:12:50] Well, I’m talking—

Dr. Chris Huiras: [00:12:52] Yeah. So that has taken a very interesting evolution. It used to involve complete mechanical prep and two or three days of oral antibiotics, taken hours apart, that were not absorbed—Neomycin and erythromycin—which sometimes caused bellyaches. We generally followed the colorectal literature as it evolved. Toward the end, the prep shifted to just some laxatives and oral antibiotics the day before.

Dr. Randy Lehman: [00:13:22] Yep. All right, so now we're basically prepped and draped widely, and you’re ready to make your incision. So, talk us through it.

Dr. Chris Huiras: [00:13:30] Okay. I like small incisions. My hands are not tiny but not gigantic, and I use magnification—I wear my loupes for virtually every open case. As I aged and needed reading glasses, this became easier, and they still make you look cool. I would make a small incision, smaller than a hand port, centered on the umbilicus. It depends on how wide or long their torso is. You feel for the ribcage and ASIS, and I center the incision accordingly.

I hate the keyhole incision, where you make a jagged line around the umbilicus. I prefer a gentle curve just to the right of the umbilicus, cutting through the fascia to find the omentum.

Dr. Randy Lehman: [00:14:19] Okay. And then you chase the omentum down to the transverse colon and carry on.

Dr. Chris Huiras: [00:14:23] Correct. I do the majority of the operation using two Babcocks and one LigaSure device. I use the LigaSure Impact, which has a small curl on the end. It’s a 10-millimeter device and long enough to reach where you need. I locate the omentum and decide whether to go to the right or left of the middle colic artery. I divide the omentum down to the transverse colon and enter the lesser sac.

I work along the gastrohepatic omentum toward the gallbladder fossa. I alternately advance the Babcocks along the colon as I free it. My left hand "paws," while my assistant holds a Richardson retractor on the right side. I always operate from the left side of the patient, allowing me to look down into the right upper quadrant.

I gradually mobilize the hepatic flexure, which is relatively avascular. Using my fingers, I isolate and cut it with the LigaSure, taking care to avoid the duodenum and the IVC. Then I work down the white line of Toldt to the pelvic brim, freeing the terminal ileum (TI) while avoiding the iliac vessels and ureter. Finally, I place the entire specimen on the abdominal wall for open transection.

Dr. Randy Lehman: [00:15:55] So, a couple of questions.

Dr. Chris Huiras: [00:15:56] Yes.

Dr. Randy Lehman: [00:15:57] Number one, the incision you made—could you get your hand in?

Dr. Chris Huiras: [00:16:02] I could get most of my hand in, or all of it for a larger patient. For smaller patients, like an elderly nun I remember, I almost pulled her entire colon into the incision! I realized then that I made the incision too big.

Dr. Randy Lehman: [00:16:18] So, when you’re pawing with your left hand, are you just gripping and pulling, then doing your transections?

Dr. Chris Huiras: [00:16:26] I also splay out my fingers to expose the area while my right hand does the transections.

Dr. Randy Lehman: [00:16:30] You mentioned dividing the omentum. Does part of the omentum go with the specimen?

Dr. Chris Huiras: [00:16:36] Correct.

Dr. Randy Lehman: [00:16:36] Okay. What I’m used to doing is pulling the omentum up and incising behind it in the avascular plane, leaving the omentum intact.

Dr. Chris Huiras: [00:16:45] Yes.

Dr. Randy Lehman: [00:16:45] So, that’s a little different approach.

Dr. Chris Huiras: [00:16:47] Exactly. 

Dr. Randy Lehman: [00:16:53] But is there any particular benefit to one or the other? I don’t… I can’t really…

Dr. Chris Huiras: [00:16:53] You could use the omentum you leave behind to fill the dead space. But I liked taking it because if there was any question of tumor extension outside the colon, I had the benefit of including extra tissue.

Dr. Randy Lehman: [00:17:09] Gotcha.

Dr. Randy Lehman: [00:17:10] Especially in the transverse colon.

Dr. Chris Huiras: [00:17:11] Correct.

Dr. Randy Lehman: [00:17:11] With the cecum, that maybe does… Yeah, yeah, and I do the same thing. So with the omentum I leave behind, I place it over the top of my anastomosis or at least wrap it. I don’t necessarily stitch it around the anastomosis.

Dr. Chris Huiras: [00:17:21] If you divide it in the middle, there’s plenty to place over the anastomosis.

Dr. Randy Lehman: [00:17:25] Yeah, that’s great. And then when you’re coming down the right white line of Toldt, are you using the LigaSure Impact for that too?

Dr. Chris Huiras: [00:17:32] I use the LigaSure Impact or blunt dissection.

Dr. Randy Lehman: [00:17:34] Okay.

Dr. Chris Huiras: [00:17:35] In rare cases, I’ll use a Bovie on an extender because the tissue is so thin, with hardly any substance.

Dr. Randy Lehman: [00:17:40] Okay. Well, I guess from a Randy Lehman perspective, that answers all my questions.

Dr. Chris Huiras: [00:17:46] I do have one other point to make. I use the stapler to create a functional end-to-end anastomosis.

Dr. Randy Lehman: [00:17:53] Yeah, up to that point.

Dr. Chris Huiras: [00:17:54] Oh, up to that point? I’m sorry. Okay.

Dr. Randy Lehman: [00:17:55] So, anyway, go on with the anastomosis.

Dr. Chris Huiras: [00:17:57] Sure. Depending on the patient’s BMI, body habitus, and retroperitoneal fat level, one of the harder parts is getting the TI mobilized enough to avoid irritating the tissue behind the colon. Once I have it up on the abdominal wall, I choose my site of transection.

I aim to be as efficient as possible, staying close to the bowel wall. Some surgeons staple the specimen, then hand-sew or staple off the defect. I typically use two firings of the stapler. First, I create a rent in the TI mesentery and the transverse colon, targeting the avascular portion. I use the LigaSure to divide down to the right colic vessels.

For the vessels, I use three large Kelly clamps—two on the patient side and one on the specimen side. I don’t suture ligate; I hand-ligate with heavy silk (0 silk), ensuring I include enough lymphatic tissue near the right colic vessels. Once the omentum, mesentery, and bowel are fully divided, I switch sides of the table.

I create a rent large enough to accommodate the stapler jaws, place the stapler in independently, connect, and fire it. This creates my functional end-to-end anastomosis. I fire the stapler again to divide the specimen and seal the defect. The specimen is removed without any spillage. I use one extra stapler load for safety, then change gloves.

I close the mesentery rent with figure-8 Vicryl sutures, usually two 2-0 Vicryl stitches.

Dr. Randy Lehman: [00:20:07] Okay. Do you place any silk sutures over the top of the anastomosis line?

Dr. Chris Huiras: [00:20:12] That’s the billion-dollar question, isn’t it? Early in training, stapler company reps would insist you don’t need to suture, imbricate, or place a crotch stitch. They said none of that was necessary. I’ve tried all the methods, but if you’re satisfied with the tissue quality and tension, you don’t need to do anything further.

Dr. Randy Lehman: [00:20:45] Your staple lines are secure without any reinforcement.

Dr. Randy Lehman: [00:20:45] Okay, well, maybe I need to get some guts. But all I do is a crotch stitch. But the other thing I do is close the common enterotomy with chromic suture and then place silks over the top.

Dr. Chris Huiras: [00:20:57] Sure.

Dr. Randy Lehman: [00:20:57] If you’re using the two-staple-load technique, though, you need a pretty long stapler.

Dr. Chris Huiras: [00:21:08] I use the 100 mm blue load stapler.

Dr. Randy Lehman: [00:21:10] Okay, so 3.5 mm staple height?

Dr. Chris Huiras: [00:21:13] Yep, 3.5 mm staple height.

Dr. Randy Lehman: [00:21:17] All right. There are a few other questions about your mesentery technique. For the middle colic artery, do you ever use backlighting or other tricks to determine your dissection plane?

Dr. Chris Huiras: [00:21:36] I like to palpate for a pulse, and I almost always can feel it. In western Wisconsin, though, many patients’ mesocolons were too thick to see through. Backlighting works for the proper patient, but it was pretty rare for me to need a Doppler to find the middle colic artery. Palpation alone usually sufficed, as long as I stayed well clear of either side.

Dr. Randy Lehman: [00:22:05] So you usually preserve the main middle colic artery, but it depends—like for a mid-transverse case, obviously.

Dr. Chris Huiras: [00:22:10] Correct. Hepatic flexure resections were my cutoff. If the lesion was proximal to the hepatic flexure, I’d resect to the right of the middle colics. If it involved the hepatic flexure or the right transverse colon, I’d take the middle colic artery for malignancies.

Dr. Randy Lehman: [00:22:33] And when you take the middle colic, you still leave the splenic flexure intact, correct? You’re still able to mobilize the TI and close the mesenteric defect?

Dr. Chris Huiras: [00:22:45] Yes.

Dr. Randy Lehman: [00:22:45] That defect can sometimes be substantial.

Dr. Chris Huiras: [00:22:48] Right. I ran into that issue more often during sigmoid resections or extended cases involving both flexures. The mesentery of the small bowel approximates easily to the colon’s cut edge, so it’s usually not a problem. I prefer to avoid leaving an internal hernia mechanism in place.

Dr. Randy Lehman: [00:23:15] Right, sure.

Dr. Chris Huiras: [00:23:17] Now, I’ve seen a variety of methods for closing mesenteric defects. Running sutures might seem efficient, but in thin patients with fragile tissue, they can tear out and create a “banjo string”—which is worse than leaving soft tissue exposed. I typically use interrupted figure-of-eight sutures. They provide enough bulk and avoid excessive knots. Plus, I can space them to alleviate tension on the anastomosis.

Dr. Randy Lehman: [00:23:58] I could discuss your techniques all day because so much thought goes into every step. I really appreciate that. I loved asking you detailed questions during cases because you always had answers. Others might just dismiss questions as, “You’re a resident—keep your mouth shut.”

Dr. Chris Huiras: [00:24:15] Right.

Dr. Randy Lehman: [00:24:16] Thank you for sharing. Anything else to add about the right colon?

Dr. Chris Huiras: [00:24:19] No. 

Dr. Randy Lehman: [00:24:19] So, I mean, obviously, we’ve really progressed in terms of our ERAS protocols and whatnot. The last three right colectomies I did in the past six weeks had the patients home on post-op day one.

Dr. Chris Huiras: [00:24:32] Excellent.

Dr. Randy Lehman: [00:24:33] I mean, it’s just getting ridiculous.

Dr. Chris Huiras: [00:24:35] Yeah, but I didn’t mind making a smaller abdominal incision for specimen extraction. I know you can make a Pfannenstiel incision and get it out that way, but for me, this was the most efficient way of doing a right colectomy. It was easily less than an hour, usually 25 to 30 minutes depending on the patient’s build.

Dr. Randy Lehman: [00:24:56] Yeah, I guess I didn’t ask—fascia closure?

Dr. Chris Huiras: [00:25:00] I do a mass closure using PDS sutures. Two lengths, so I can start at either end and tie it with a single strand.

Dr. Randy Lehman: [00:25:09] Single strand or double-strand?

Dr. Chris Huiras: [00:25:10] I switched to double-stranded PDS near the end of my career.

Dr. Randy Lehman: [00:25:15] If the patient had 4 cm of subcutaneous tissue, did you ever close the subcutaneous layer?

Dr. Chris Huiras: [00:25:22] I did not. I was very meticulous about caring for the subcutaneous tissue after the fascia was closed, ensuring perfect hemostasis and using copious irrigation. The times I ran into trouble were when I used Vicryls to close the subcutaneous layer.

Dr. Randy Lehman: [00:25:39] Okay, and what did you do for the skin?

Dr. Chris Huiras: [00:25:40] I used Monocryl for virtually all closures.

Dr. Randy Lehman: [00:25:43] Yeah, great. All right, well, let’s move on. We could talk all day about this and other things, but at some point, you have to draw the line. The next part of the show is the financial corner.

Dr. Chris Huiras: [00:25:56] All right.

Dr. Randy Lehman: [00:25:57] This is somewhat of a personal passion of mine. I think everyone is on a financial journey, and the more we can get it under control, the less we have to worry about it. That way, we can focus on the things that really matter. If you had a financial tip for a junior resident or a new attending, what would it be? The floor is yours.

Dr. Chris Huiras: [00:26:19] I would say buy a smaller house than you think you need. You spend all this time in training with delayed gratification, and then you start earning and feel like you deserve a mansion or a giant house. Realtors and recruiters will push one on you, but then you become a slave to your house. If your practice starts slow, you’re stuck wondering how to make those house payments. A smaller house gives you financial flexibility and allows you to respond to community needs, charity, or time off without financial strain. You’re not a slave to your house.

Dr. Randy Lehman: [00:27:15] You sound like you’re speaking from experience.

Dr. Chris Huiras: [00:27:17] Yes, sir.

Dr. Randy Lehman: [00:27:20] Tell me more.

Dr. Chris Huiras: [00:27:21] I got excellent advice from a college professor I knew through Bible study. He said, “You’ll be offered a lot, but start out modest.”

Dr. Randy Lehman: [00:27:37] So you managed to follow that advice?

Dr. Chris Huiras: [00:27:38] Yes, I did.

Dr. Randy Lehman: [00:27:38] Nice.

Dr. Chris Huiras: [00:27:39] Yep, and I still live in the same house I started out in.

Dr. Randy Lehman: [00:27:43] Wow. I have three follow-up thoughts to that.

Dr. Chris Huiras: [00:27:47] Okay.

Dr. Randy Lehman: [00:27:47] First off, have you heard of Robert Kiyosaki? He’s kind of a guru in the personal finance space.

Dr. Randy Lehman: [00:28:10] And one of his books, Rich Dad, Poor Dad, has changed a lot of people’s lives. There’s a lot of debate about it, but it has good concepts. It talks about your house not being an asset.

So, it is an asset—on your balance sheet, you own it, you could sell it, so it’s technically an asset—but it’s actually an asset under the bank’s balance sheet.

Dr. Chris Huiras: [00:28:15] Right.

Dr. Randy Lehman: [00:28:16] For you, your house is more of a liability because what does it do? It costs you money every month. His argument is that an asset makes you money every month and doesn’t lose you money.

People often say their house is the best investment they ever made, but that’s usually because it’s the only investment they’ve ever made. I guarantee you, compared to some investments I’ve made, there’s no house that’s going to be as good of an investment as actual financial investments.

Dr. Chris Huiras: [00:28:46] Correct. I would fully endorse that.

Dr. Randy Lehman: [00:28:49] Then there’s this. I remember when I was an intern on plastics. There was a chief plastics resident, and it was around Super Bowl time. He was finishing residency and had just signed a new contract.

This was when curved TVs were becoming a thing. We were sitting around doing morning rounds, and he started talking about this huge curved plasma TV he’d just bought. It was longer than me, and he put it in his basement. He had just signed his contract, hadn’t done any work yet, and bought it on 90 days same-as-cash.

So many people spend their paycheck before they’ve even made it. I mean, just watch the game with your friends. It’s not about the TV.

Dr. Randy Lehman: [00:30:00] Let me tell you a personal story. The first house I bought in Winamac, Indiana, was $86,000. I’d heard about physician mortgages where you could put no money down and not pay PMI.

Dr. Chris Huiras: [00:30:19] Oh, yeah.

Dr. Randy Lehman: [00:30:19] So, I called a bank. I already had a house picked out and under contract. The guy said, “Oh, yeah, we’d love to lend up to $750,000—no money down, no PMI—and up to $1.5 million if you put 5% down.” I thought, “Great! This $86,000 house should be no problem.”

But then he says, “Actually, hold on. Your job doesn’t start until July, and we only do this three months out from the start date. So, we can’t qualify you for this.”

I said, “Okay, no problem. Use my current job as a resident. My salary should cover it.” But then he says, “Since you told us that job is ending, we can’t use your salary from that job.”

So, I called my regular banker, who I’d worked with before, and said, “I’ll put 20% down and just buy the house.” He agreed, and I bought the house. Sometimes it’s just easier to pay it off and have the grass under your feet. That’s another thing to think about.

Dr. Randy Lehman: [00:32:15] Yes, but you have to think about every little piece of the math as it pertains to your scenario. A lot of people end up house poor. The other problem is that once you buy the house, you then feel like you need furniture to match the house, a car for the driveway, and you have to pay the taxes, insurance, and heating bills. It’s not just the loan payment—it’s the whole lifestyle. Then there’s private school for the kids.

Dr. Chris Huiras: [00:32:26] That’s rarely part of the equation when people are making that decision. But it’s very valid. It’s really true.

Dr. Randy Lehman: [00:32:33] So true. You hit the nail on the head with the house, and now you’ve got me fired up. So that’s good.

Dr. Chris Huiras: [00:32:38] I can see that. Let me ask you a follow-up question. When interest rates were falling, I finagled a 2.5% loan. I can pay off my mortgage—I have about two years left—but I’ve kept it because my other investments are earning far more. Depending on my tax status, I might even deduct the mortgage interest. So, while I still owe a little on my house, I don’t see a downside.

Dr. Randy Lehman: [00:33:11] Right.

Dr. Chris Huiras: [00:33:11] It allowed me to be nimble financially. I think we’re of one mind about starting out small, and that’s really good advice. You can always upgrade later. Or, if the housing market changes, or you don’t like your job, you’re not stuck.

Dr. Randy Lehman: [00:33:29] Exactly. You give yourself so many more options by not overcommitting. Well, thank you for that. Let’s move on to the next segment of the show, called Classic Rural Surgery. Share a story that happened to you that represents classic rural surgery.

Dr. Chris Huiras: [00:33:45] I can think of some patients that truly represent the poverty in Monroe County. For example, I had patients who couldn’t afford the gas money to drive 26 miles to La Crosse. They could see me in my clinic in Sparta, but if they needed a follow-up or a test in La Crosse, they couldn’t make the trip. I saw this as part of my outreach mission. It was one of the most gratifying aspects of my practice—bringing high-quality care to people who needed it most.

Dr. Randy Lehman: [00:34:28] Did you ever have a case where you believed a patient needed higher-quality care elsewhere, but they couldn’t access it?

Dr. Chris Huiras: [00:34:45] Yes, I had a lung cancer patient who needed surgery in Rochester, Minnesota. It took months just to get her diagnostic tests done. She couldn’t make the trips because of transportation and financial barriers.

Dr. Randy Lehman: [00:34:59] That’s tough.

Dr. Chris Huiras: [00:35:00] There was another case on a weekend I was on call, two weeks after the opening of deer season in Wisconsin—which is like a national holiday. An Amish family brought their son to the emergency room. While cutting up his deer, he accidentally followed through and stabbed himself in the thigh. He had arterial bleeding at the time. The family applied tourniquets and, interestingly, ground red pepper as a coagulant.

Two weeks later, he started leaking from his leg again. I suspected he had developed an AV fistula. I took him to the main hospital in La Crosse, explored his leg, and repaired a muscle branch artery injury. About two months later, his father called me to thank me. Amish typically don’t use telephones, but they have excellent neighbors who helped him make the call.

And he called me and said, "My son cut his forehead open last night while ice skating, and it’s going to cost me $500 to go to the Black River Falls emergency room. Is this something you could do?" I said, "Meet me in the parking lot of the clinic, and I’ll see him."

This was a Sunday morning around 10 a.m. He came in, and his son had been on his friend’s shoulders while they were ice skating. He fell off and cut his forehead open. It was a big laceration, a few hours old, but clean, and I was able to repair it.

After I prepped and sutured it, I turned around, and his dad was standing there with an apple pie and a $50 bill in his hand. He said, "Word is starting to get out about you. Do you like these kinds of side jobs?" I said, "Well, I can’t do X-rays or get you medicines, but this kind of stuff is right up my alley."

Then he asked, "How am I going to get my pie plate back? I might never see you again." I said, "Just a minute," went to the nurse’s break room, found two plates, flipped the pie onto one, and gave him his pie plate back. He called me another time about an injury one of his kids had. I think it’s a great story about being on the front lines in a small town.

Dr. Randy Lehman: [00:37:59] That’s classic rural surgery. Great. So, the last segment of the show is Resources for the Busy Rural Surgeon. Rural surgeons have a lot on their plate.

Dr. Chris Huiras: [00:38:09] Yes.

Dr. Randy Lehman: [00:38:09] Where can they go for quick answers?

Dr. Chris Huiras: [00:38:12] That’s a great question, especially if you’re by yourself. I used UpToDate—our institution subscribed to it, and it’s an excellent resource. I also think you have to rely on your friends. Any colleagues or friends you made during training—whether they’re your teachers or residency classmates—having someone you can call with a question is invaluable.

Dr. Randy Lehman: [00:38:41] That’s been a recurring theme. You also brought a book with you.

Dr. Chris Huiras: [00:38:46] I did.

Dr. Randy Lehman: [00:38:48] It’s a good shout-out.

Dr. Chris Huiras: [00:38:49] Surgical Clinics of North America. Tyler Hughes—Dr. Hughes, thank you very much for pioneering this. One of my colleagues authored a chapter in here, and it’s a great resource for many of the practical aspects of performing rural surgery.

Dr. Randy Lehman: [00:39:08] Well, Dr. Huiras, thank you again so much for being on the show.

Dr. Chris Huiras: [00:39:13] Thank you, Dr. Lehman.

Dr. Randy Lehman: [00:39:13] It’s been an honor, and I really appreciate everything you’ve done for me during my training. Thanks for watching, everyone. Don’t forget to like and subscribe, and tell your friends if this has been helpful. We’ll see you on the next episode of The Rural American Surgeon.