Chapters Transcript IVC Filters Course: Venous Thrombosis Update 2025 Well, thank you very much. Again, it's an honor to have the podium. Uh, I wanna acknowledge the unbelievable work that's been done by the directors of this course, Doctor Halpern and, uh, Doctor Pereira. It's a testament to the talent that exists at NYU. Uh, I joined as the director at the, uh, of the hernia program at, uh, the Manhattan office, but, uh, clearly a lot of talent, a lot of people that are doing wonderful work in the hernia world here at NYU across the uh entire health system. So today we're gonna talk about abdominal wall surgery. We're gonna spend a lot of time over the course of the day learning about technique, uh, you know, a whole day dedicated to tons of different new approaches, faculty presenting on their strategies for hernia care, and right now we're probably just scratching the surface of what hernia surgery looks like in modern day. These are my disclosures. I do serve as a consultant for multiple groups. Xavier talked a little about my uh journey through abdominal wall and training, um. My journey started at the University of Michigan. I was a trainee there. I, I had no intentions of becoming an abdominal wall specialist. During my time at Michigan, uh, my 1st 34 years were dedicated to, you know, just expanding my clinical practice, uh, awareness, and then I was gonna go into colorectal or surgical oncology. And then I went into the lab, did 2 years of research, and when I came back, the hernia service was a completely different place. Uh, we had gone from doing a bunch of eye palms to doing tar. Uh, we were just learning how to do tar, and I remember standing at the, uh, in the OR you was struggling through a relatively straightforward tar at the time. And I looked at my chair and I was like, can someone specialize in this? And he looked me dead in the eyes and said, this is the future of like the next like domain that I think is really gonna expand, you should really consider it. So, the next day we struggled through a tar again, and I said, I want to specialize in this. This was 2 days deep into the service. He said, well, there's only 2 fellowships, and it was Cleveland Clinic and uh Yuri Novitzky's at Columbia. Uh. They called uh Cleveland Clinic. They had already uh matched the fellow. Yuri Novitzky at Columbia had just moved to Colombia and didn't have a fellow, and we sent them my CV. And he said, why don't you fly out, let's talk, and let's see if we can make something happen. Before I knew it, I became his fellow, and that kind of has been one of the best decisions of my life. Two days in and uh into a service and decided to go after a specialty I was really passionate about, and it's opened up a lot of doors for me. The fellowship was wonderful, and my time at OHSU was very special. 5 years dedicated to really, really hard work. Intercutaneous fistulas, mesh complications, loss of domain, and uh the full spectrum of hernia disease, and developed wonderful relationships and mentorship programs, and I'm very excited now to join NYU and start building for the future. So today we're gonna discuss how hernia has evolved. Hernia surgery has evolved over the last decade. We're gonna highlight what makes a hernia program a true center, and we're gonna forecast what the future may look like. The burden of hernia disease is high. Uh, you know, hernia disease isn't just about fixing holes, it really is about reestablishing someone's core health and quality of life. And so we call ourselves quality of life surgeons, and what we're aiming to do is improve someone's quality of life. You know, that person in that corner there, open abdomen after necrotizing pancreatitis, a disconnected duct, uh, we had to do a completion uh pancreatectomy and abdominal wall reconstruction. The CT scan to that person's right is a patient with a traumatic injury, open abdomen, skin graft over bowel, where we reconstructed them, that flank hernia after a transplant, uh, another patient after an open abdomen was basically seeing their visceral peristals over the under the skin graft. These are patients that really want to reestablish normalcy, and that's what we get to do as hernia surgeons. So let's start talking about how we've arrived to where we're at. If you know, you know, right? The hernia surgery in the last decade has evolved dramatically. What hernia surgery was 20 years ago, 10 years ago is very different than what it is today. Currently my practice, about 20% of what I do aligns with what I did in my fellowship. Everything else is very different, you know, whether it's utilizing robotics or using uh uh novel techniques, uh, even in 56 years from fellowship, your practice will change, and that's just demonstrating how much we have to learn about hernia surgery. So how do we get to our current state? What is pushing us forward, and then what are the barriers we have to overcome to get better? So when you talk to surgeons about what pushes them to change and what prevents them from changing, it's actually quite interesting. It's kind of an interesting psychologic study, and surgeons definitely have their own opinions about what makes them change, right? You could ask me and Doctor Pereira right now, like what pushes us to change and what makes us stay the same, and right now it's fifty-fifty mix. Like some surgeons, what they call a barrier, others will call a facilitator. So, really it's about understanding your audience, understanding and explaining your rationale, and coming up with a strategy that's gonna entice people to work towards better. So let's look at hernia surgery and talk about things that for some reason don't make sense. Prevention, for instance. So who here uses a small stitch technique when closing an abdomen? That's impressive. That's better than most places, like, so again, like that's, that's really nice, but when you look at the United States, it's poorly utilized stitch technique. There's a fair amount of science supporting it, but there's a lot of nuance, right? Like using the right suture, the right needle, uh, growing the right type of knot even is really important. If you throw surgeon knots, it's gonna be prone to burst. And so there's a lot of science, but most surgeons don't do it. And why is that? Surgeons have biases, and we actually interviewed a bunch of surgeons around the country, asked them, what do you, what makes you not utilize this technique that many people think is a great way to reduce hernia rates? And a lot of people cite patient BMI or suture size concerns with suture burst, or whether or not the studies are applicable to their populations. And it's not just a US problem. Canadian surgeons, very similar results, and across the board, even in Europe, uh, there's hesitance to change practice when something supposedly works. And then on the other end of the spectrum, we will find certain things will really take off in spite of not having much data. So let's talk about robotic ventral. Though early ETTEPP outcomes, there were no RCTs, there was very limited long term, but there was tons of uh adoption of this technique. Many people became very enthusiastic about ETEP because it made sense. Um, when you look at these studies, like this was back in 2021, it's a little dated, but at this time, robotic tar was really taken up. You could just go online and search robotar course and find tons of courses, people training people how to do these techniques, and everyone was very enthusiastically introducing this into their practice. And then back in 2021, RCTs, only 237 patients had been studied long term. And so there wasn't a lot of data, but a lot of enthusiasm. So, hernia surgery doesn't always make sense. It's not about what's being published, it's sometimes about other factors, multifactorial in terms of how we're evolving. Surgeon a variation of of uh application of techniques, like we have so much variation, like surgeons won't necessarily ascribe to a certain technique just because others are doing it. We see a lot of variation. When we look at how we got here, I think one of the biggest drivers for quality improvement has been multi-centered collaboratives. You know, the ACHQC doesn't always get, uh, you know, a lot of positive press, especially around here, but I think Quality initiatives like this have been great examples of how we can work towards better as a community. I think NYU is poised to do something special, multiple sites, a lot of expertise under one umbrella. Hopefully, we can work together as a collaboration amongst all of us to improve hernia care across our system. Uh, but collaboration works, and I think collaboration is the new competition. Uh, you know, we've definitely seen improvements in outcomes and standardization of care with regard to collaboratives. I think for hernia in in particular, because it's so technical, and we can't really depend on multimodal therapies or, you know, radiation or anything, we basically just depend on our technique and our decision making. Uh, a lot of web-based forms taken off and have been very important to dissemination of technique. Things like international hernia collaboration, video libraries that exist uh through, you know, uh sponsorship from various companies, as well as through societies. There's a lot of ways to improve your understanding of hernia disease, uh, just digitally from the comfort of home. The influence of the online platforms is pretty impressive. A lot of surgeons utilize them. And I think for me, IHC has been a great opportunity to learn post fellowship, and you, you get introduced to new techniques, new technology, can talk about new uh innovative techniques, and it even feedback on complex cases. The vast majority of things when we review what it looks like online, is quite good. 97% of responses are appropriate. Sometimes they're not so helpful, but for the most part, I think you get a lot of good feedback as to what you're doing. A lot of other mechanisms uh for quality improvement, so video-based education is a big part of my practice. I love recording videos. My bedside assistant always knows I like my camera clean, and uh we always talk about doing it for the gram. So with my residents, I'm always telling them, throw me a good stitch, make sure it's gonna end up on the gram. Uh, so YouTube, I think is a great means to learn. Uh, these are some of my favorite hernia surgeons on YouTube that I watch, admire, and learn from. Uh, I run my own channel, and I think it's been fun to explore and, and get feedback from, uh, the community, sometimes positive and sometimes not so positive. So I saw it on Facebook. I think one of my favorite things that happened to me was, back in 2023, I was doing what was gonna be a preperitoneal hernia repair, and then during the operation, I ended up saying, you know, there's a little tension, why don't I release the posterior sheath? And that was basically a preperitoneal lira, and we're gonna learn all about that later today. I did the case, it went really well. I posted the video some months later. And then within a week, like someone was like, hey, you shouldn't call that a preperitoneal lyra, you should call it a tapper. OK, I kind of like the ring to it. Uh, so we called it a tapper, which stands for tap with rectus apineuroplasty. Um, within 7 days of that video, I had 5 surgeons from India, Australia, Europe text me or message me, letting me know that they performed the technique in their office or in their hospital. And I was like, can't believe it. 7 days, 1 video, no RCTs, yet now this technique's been disseminated across the globe. Fast forward a year later, we published in Jaws. Actually Xavier was the special editor for that particular article. He's like, you should, you should publish on Tapro with us. I was like, OK. So then fast forward another year, and now we have a multi-institutional study, uh, Aram is gonna be talking about it, and we have a lot of people performing this operation that has one publication and a few videos. So clearly hernia is evolving very differently in medicine than traditional means of dissemination in medicine. So NYU were very excited about the hernia program, but what makes a hernia center a center? And hernia centers have been described. If you Google hernia center, you'll find 1000 of them right now, probably within 50 miles of here, right? So, what makes a hernia center special? I think there's a lot of characteristics. It can't just be about closing holes, it can't just be about volume. I think it has to be multi-pronged, right? Like you have to not only do great work and take care of patients, but I think you have to contribute to the advancement of the field, and this symposium, I think is a great example of that, right? Bringing people together, not just surgeons, but nurses and the people that are the at the bedside, frontline workers helping us support patients. To understand the why and the rationale for what we do. And so there's a lot that goes into building a true hernia center of excellence. Characterizing these and looking at some of the stellar programs across the country, you'll see that research is a big part of it, education is a big part of it, and not just having one person to turn to, but rather a team that's gonna take care of these patients. And that's something we're gonna work towards at NYU and something we already have the foundation built out for, fortunately. When I think about the essentials, I think about longitudinal care, not just after surgery, but even before, risk stratification and optimization, technical expertise, surveillance, and then working towards better. So what does it mean about longitudinal care? This was my equation for success in hernia when I graduated fellowship, right patient, right operation, right approach. And the right patient becomes a really important element of this. The, the thing is that the surgeon has to make that decision, so you are gonna really impact this variable. Because we know the more you operate on hernias, the faster they come back, and the less likely they are to have a successful outcome. So, doing the right operation on the right patient is really critical. Optimizing them. Uh, making sure that, you know, these rates drop, right? Incisional hernia rates 10 to 40%, recurrence rates upwards of 44% in modern day surgery. We gotta get better at that. We gotta break this vicious cycle, right? So hernia repairs, some complications happen, next thing you know, you're dealing with a recurrence that's gonna have a worse outcome, and then these poor patients really start with a small hernia that turns into something that has to go to a specialist. So what does that look like? Optimization. Optimization was something we really focused on at my past practice, and it's something I hope that we can really focus on here. Diabetes control, weight loss, and smoking are often the big three that we talk about, but it's more than that. It's really about finding any opportunity to get better, uh, and really working with the patient. It doesn't have to be an absolute cutoff, but rather a goal. Our goals are to enhance that physical conditioning, reverse deconditioning that happens with surgery, and increase functional reserve. And the reality is it's resource intensive. Um, a lot of the pre-op optimization takes a lot of time, uh, it can, uh, you know, be potentially cost prohibitive, and that's why I think centers matter. But if you build it out and you don't build it out the right way, your success won't be that high. So this is a study out of University of Michigan. I was not involved in it, but um they used a PA screening aid, so they would basically just have patients screened for whether or not they needed optimization in in advance of hernia care. And what they found was when these patients were screened, they would then meet with a PA who would guide them to optimization. After a year, only 9 or 91% of patients did not improve their optimization metrics and were not operator. So you could look at that as a 9% success rate. I think the real key is getting that surgeon integrated in that optimization program and defining really what is gonna be the goal for that patient. So at OHSU we were really big on optimization, but we were very careful about how we defined it. So, it wasn't about everyone being a BMI 35 or lower. It was about trajectory, it was about improving outcomes, and so, We set up a physician directed program and had a lot of support from our APPs. And what we found was that within 6 months to a year, we would fully optimize across like the standard metrics 30% of the time, partially optimize and offer surgery another 30%. And then there was no progress in about 40% of patients, but these were patients that were safe to observe, you know, BMIs of 60, 65, with large hernias that were not at risk for incarceration, strangulation, or complications. And so optimization, I think you have to really cater it to the patient needs, so you can have a good outcome. But today we're not here to really talk about optimization, we're here to talk about these things, right? Right operation, right approach. And the first thing you need is expertise, and we're surrounded by expertise. We have Doctor Malcher, who's here visiting us, who's done a great job in Uh, initially, like setting up the program here at NYU at Manhattan, but we have tons of wonderful, uh, surgeons here at NYU, uh, who are either trained by Doctor Mascher or have partnered with them to improve. So I'm really excited about partnering with all of these experts along with all the people that are not pictured here to build out something special. And why do we need expertise? Because this is what it looks like. If you talk to a modern day a fellow, these are the kinds of operations they have to be comfortable doing, right? Lira, iPalm, iPalm plus, tap, it's like an alphabet soup that's quite confusing. And so, uh, and this, this pretty much grows on a, a monthly basis. Every month someone comes up with a new, uh, you know, algorithm or a new way to treat for. And where is hernia surgery going? I think more and more we're realizing that it has to be a specialty. So the European uh hernia surgeons have done a wonderful job of defining what hernia specialization looks like. And being very systematic about it. And I think the AHS is working towards this. Uh, the fellowship council now has 10 designated sites, um, and we're all working towards standardization of, uh, curriculum, as well as understanding that the hernia disease is a true specialty. So, while I really acknowledge and I commend any surgeon who wants to fix the hernias that they cause, I think we have to acknowledge that some hernias are better treated by the specialists. This is what it takes. You gotta understand the abdominal wall, you gotta understand prevention, you gotta understand diagnostic tools that are gonna be used to assess the problem. Understand indications, and then manage patients preoperatively. And have a good robust and wide armamentarium to treat patients. But when I operate, my residents, whatever is listed as the operational performance is usually not what we end up doing. It's kind of just ventral hernia repair, robotic ventral hernia repair open. We don't talk about tar tap or anything. We sort of go into the case and see what the body gives us, and call the appropriate audibles to get the job done for the patient. And so the the surgeon has to walk in with a fund of knowledge that they can handle and address the right thing for the right patient at the right time in the operator. And this is why it matters, you know, patients like this will show up, right? So it's a big hernia, but she also is dealing with active diverticulitis. She's lived with this hernia after a tram flap for 20 years. She has no sidewall, it's all blown out, and now she has been admitted to the hospital 5 times with diverticulitis. She's been managed with IV antibiotics, and no one wants to do this operation. So what do we do? We strategically plan to do a sigmoid colectomy. We wanna make sure that we don't give this patient an ostomy cause that will be a disaster, a primary anastomosis, and then a concurrent abdominal wall reconstruction. And this is a life changing operation for this patient. You know, paniculectomy, what are we doing here? We're using that hernia sack to reconstruct the visceral sac, to allow for extraperitoneal mesh, uh, we're excising skin, we're managing skin and soft tissue in a patient that's relatively, uh, you know, poorly optimized for surgery, but we had a good outcome. For patients like this. This is a 30 something year old guy who was actually just taking Ozempic kind of for uh, I would say cosmetic reasons. He was a skinny person like. BMI 30, trying to get the BMI 25. And uh ended up having uh necrotizing pancreatitis, open abdomen, and that's a big skin graft over all of their viscera. How do we manage that, you know, so we excise the skin graft, reconstruct the abdominal wall, and that's him 6 months later, a life changing operation. I will say that his wife was still wondering if I could make the scar revision better, so you'll never win in a hernia, but the bottom line is like really thinking about these patients and understanding that it's more than just a hole that we're closing. Long term surveillance also matters. So, the vast majority of patients that come to my clinic with recurrences do not come in after like a tar. A lot of patients are starting to dwindle, like come in like that, but the, the vast majority are coming in after simple repairs. You know, I had an umbilical hernia repair, I had a tap, I had an eye pump, but now it's back, and I'm a hernia maker, right? They don't usually go back to their index surgeon, so we queried. queried over 200 consecutive recurrent hernias that came into practice, uh, and less than 10% went back or, or even informed their index surgeon of the recurrence. So, it's really important for us as surgeons to surveil, or else you will not know your outcomes, you cannot actually iteratively improve. And so surveillance is a big part of what we do, uh, built out a surveillance program and how did we do it? So our pre-op. Uh, or a post-op surveillance program was something that every patient was asked to join, and we had about a 99% rate of joining, joining it right after surgery, and we had about an 80% surveillance rate at one year. And I'm very proud of that. It was for inguinals and dentals included, which gave us a great awareness of what our true outcomes were, not just recurrence, but patient, uh, quality of life metrics as well, cause we are quality of life surgeons. So knowing what surgeon outcomes were like, let us improve and continue to get better. And so we talk about all of this, and it's really about research as well, so that we can improve the field beyond the walls of our institution. And so hernia surgery, if anyone's interested in publishing, uh, there's always a lot of opportunities to publish, the there's a lot of interest from journals right now. And the good news is in hernia care, when you look at guidelines, the vast majority of our recommendations are either low or very low. So, there's tons of room for improvement, right? So, hernia surgeons, most of the time, we're just pontificating about what we think is the right answer. For me, uh, telehealth surveillance, telehealth patient management is really important, but I try to like practice what I preach, even in research and education. This is a picture of my lab. It's a hernia lab. Actually, two of the people, this is when I was in Oregon, two of the uh residents were in New York City, one was in Saint Louis, one was in Alabama. No one was in Oregon. And I love that about the lab. It's, we bring like-minded people who are interested in learning about and researching the same topic in a research, you know, uh or a research uh conscious environment and, and connect and do research together. And we looked at telemedicine as well, you know, like taking hernia care to the comfort of a patient's home, thousands of evaluations over the last 5 years, uh, a lot of pre-op optimization. Uh, we had 100% digital programs for certain patients, including big ventral hernias, recurrent hernias, where the only time they would ever see me in the flesh was on the day of surgery or during their hospitalization. Everything else was managed. You know, virtually, and it made a big difference for my population in Oregon, cause commutes were so long. We published on it, you know, we didn't just practice it, we actually tried to understand it. We developed inclusion and exclusion uh um uh criteria. We looked at what were the outcomes. We have multiple studies now being published on long-term outcomes after virtual only care, um, and we've developed a lot of sort of nuance to these decisions that we make. Education, again, we're all here to learn, and how is education improving in hernia care? We're really using technology. Laparoscopic surgery is still something many of us practice, but I think the laparoscopic environment is not the best as an educator. You'll hear the Uh, you know, the same things happen, especially like for inguinal hernia, right? Like a demoralizing operation for a poor resident, right? You do that walk of shame. Once you cross over, no one's coming back, and no one's getting the case back, right? Robotics, I really get to teach my trainees and my residents in a much better way. I, I get to take the instruments back, get them back in the right plane, and give it back to him. Uh, so here are the ways I teach, you know, uh, so Jamie, we'll be working together soon. Hopefully you don't see this, right? This is me doing the entire case and you watching. Uh, that's faculty Wellness Day, that's when I had like no one on the bedside, or we're just gonna use this as a video or something, right? So faculty wellness days happen sometimes, I hope not too often. This is what it looks like when it's like a resident that I really wanna keep on track, like 10 on, 10 off. And so this is usually my junior residence. I'll put a timer, it's loud and proud, as soon as 10 minutes hits, it's like the freeze bell back in elementary school. So you'll freeze, we back, pass it back over, and then if the resident struggles, obviously I'll get him back on plane or do the right thing. And then we go until you can't go any further. The resident does the majority of the case. I jump in, and these are my favorite timelines. This is where we love seeing, I love sending these screenshots to the residents if they don't have the app, uh, where I basically jump in just for like a spot check. Let me show you how to manipulate this tissue, let me show you how that dissection should look for like a half second, and then give it back. Oh I love that. That's usually demonstrating a really advanced learning it's like taking it to the next level, you know. But there's a lot of ways to get better. So if anyone's sitting in this audience, or is on like the webinar and wants to get better, there are tons of resources to get better as a hernia surgeon. So the webinars, we run them all the time. Uh, workshops, uh, we have some people that are here who have gone to our workshops, you know, uh, over my 5 years at OHSU we hosted over 200 surgeons who came in to observe us operate, uh, from around the world, from Japan. Uh, from, uh, Brazil, a lot of places, and it was wonderful. It wasn't just about how do we do these operations. It's about how do we set up a program? How do we select the patients. Some people would come for upwards of 2 weeks and learn, and I think it was a testament to people's enthusiasm to get better. And the fellowships are expanding at at NYU, obviously, uh, we have a fellowship that's centered around abdominal wall and for gut surgery. Uh, the future is very bright with the likes of Jamie uh Benson, who's here in the audience, who's gonna do great. Uh, I've only had an opportunity to talk to him, but he's a very mature, uh, surgeon, and I think he's gonna do wonderful. And then we recently just matched our next fellow, Leah, Leah Connne, who's gonna be coming by way of Saint Louis, uh, who's gonna do wonderful things in the future here in New York City. So in conclusion, hernia surgery is evolving, right? There's a lot of ways to get better. That's what we're all here for today. Um, the evolution, uh, is fueled by a lot of things, I think, a technique driven for sure. Uh, hernia centers are gonna become more and more prominent. The American Hernia Society is gonna uh have a designation for hernia centers and hernia experts. Uh, and then, uh, as we get into that space, I think standardization of care will likely happen. So with that said, I wanna thank everyone for the very nice welcomes that I've had over the course of the last few weeks, and I really wanna acknowledge the wonderful work of the course directors in setting up what I think is gonna be a really educational day. So thank you everyone. Published April 11, 2025 Created by
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