BTK Training in AWR

Welcome back to another episode of Behind the Knife from your Carolinas Medical Center hernia team. We're joined again by familiar faces Dr. Henniford who is a professor in chief of GIMIS at Carolinas. Dr. Augustine, who's also a professor of surgery at the Carolinas. And then Dr. Pulse, who's currently at Baptist Health in Miami.

And then myself you, so I'm the minimally invasive surgery fellow right now at Endeavor Health, formerly North Shore outside of Chicago. So today we're going to be talking about a topic that is near and dear to us. This is training and hernia and abdominal wall surgery. This is a topic that's evolving pretty rapidly and is taking shape in America and kind of formalized ways.

And so, we're very excited to talk about this. General surgeons have been receiving training in hernia repair for over 100 years, but you know, within the recent time period, there are more and more people who are doing hernia surgery and

therefore training others to do the same. There are even specialized advanced training programs now that are designed to produce abdominal surgeons.

One of the very first programs to do that was here. And so we're gonna get These things started off with Dr. Henniford talking about his approach to training hernia surgeons and the experience that he's had at Carolina. So, Dr. Henniford. Thanks very much, Sully. The hernia fellowship that we have here really didn't start as a hernia fellowship and I still don't call it a hernia fellowship.

It's a complex GI surgical fellowship and hernias are, have become a big part of it just because of our referrals. base with hernias. We started our fellowship 25 years ago doing million bases of surgery. Hernias were part of that. We began to see a real need for science in hernia repair. And we began to focus on that.

And with that focus in the science and beginning to write about hernia

repair and complex hernia repair, our referral base grew. If you look at the hernia surgeons that we've trained here, we've trained eight presidents of the America's Hernia Society, people who've been elected to be president of America's Hernia Society, federally president next year which will make eight.

And then if you look at the people that they've trained it's been a really remarkable ride here. But I'll just tell you that almost nobody who came here. to do our fellowship, wanted to do hernias. And they came here for the complex minimally invasive surgery. But once they got to their academic institutions, what they found was, is that they could fix hernias and were experts at it.

And so once a young surgeon who, if you look at, you take people like Yuri Novitskiy and Mike Rosen and Alfie Carbonell and Igor Belyamsky and, Will Hope and those guys. Once they fall into a position at an academic institution where they are real experts and can drive a practice and change

the arc of care in an institution, all of a sudden they then will focus on that.

They become very passionate about it. And you don't have to say much about those guys I just mentioned. They've gone on to have incredible careers in abdominal reconstruction and many of them actually focus only on abdominal reconstruction now and have driven the practice. The being a hernia surgeon to designate as a hernia surgeon for a long time, especially when I was young, people didn't want that.

It's a, it was a, you wanted to take care of cancer, you know, you wanted to do complex foregut surgery. doing hernia surgery or being labeled as a hernia surgeon was I guess you were a secondary citizen in the world of surgery. It's not, it's not like that anymore. And we have young people now can see that this is a true specialty, that being able to take someone's abdomen apart and put it back together again.

And it's not just what happens in the operating room. It is a true specialty from the time the patient walks in the door,

getting them prepared for surgery, doing the operation, and then the rehabilitation afterwards. This is, you can transform patients lives. It's, it's not just reconstructing admin, it truly is reconstructing lives, and you can become very passionate about this.

And there, there are patients that require specialty care. I will say, and I'll back off for one second here, Sally, and I'll just say that you've heard me say this many times, that the best hernia is repaired at home. We need to be able to train general surgeons to fix the standard inguinal hernia, ventral hernia, and those sorts of things, and repair them at home.

When I talk about hernia specialists, hernia specialists should be doing complex cases, the reoperative cases. Cases that, that will require, you know, ICU care, specific physical therapy broad based prehabilitation and those sorts of things. Having a,

a specialty in hernia repair and seeing its growth over the last 20 or 25 years really is quite remarkable.

Thank you so much, Dr. Hennifer. Dr. Oggenstein, to follow up on that, somebody who's trained tons of surgeons and hernia surgeons as well. What do you think really stands out about making a good training program in hernia? Yeah, thanks, Sally. So I actually was a fellow 14 years ago and exactly right what Todd said.

I didn't come to do hernia surgery and I came in for an M. I. S. fellowship, which that was this was, you know, always regarded as one of the best M. I. S. fellowships. And that's what I wanted to do s O. I think one of the things is that becoming part of this program. I've seen that it's really it's not always about doing everything in my ass and it's all not always all about.

Doing hernias. So it becomes, you know, with the recognition that there's not just one way to fix a hernia. It's not like we're going to do every hernia robotically in this

program. So, you know, you're really kind of adapting with a minimal invasive approaches. Those are just kind of like the tools that they use.

You will have in your tool belt, which I think is important for anybody listening this podcast and trying to figure out where they're going to go to do you know, a fellowship is just really important for you to be able to go somewhere where you're going to get the necessary tools. So when you are seeing patients in an office, you're able to say, well.

I'm going to do this robotically versus this case here. I'm going to do a paniclectomy and I'm preparing eventual hernia repair. I think one of the things that's really missed when we talk about hernia training is what goes outside of the operating room. And we do, you know, spend time in clinics.

That's just normal for surgeons. But I think some of that. Part of my training is not something that you really even think about, but you learn so much about being not just a hernia surgeon, but a good surgeon and figuring out because we see patients from all over the country, sometimes from all over the world that come in with really complicated problems, and many surgeons have passed them.

So how do you break down some of

these very complicated problems? And, you know, prehabilitation is one of the biggest things. How do we help these patients lose weight? How do we inspire them to quit smoking? How do we get them to get their hemoglobin A1c, you know, under seven? And when, and then we also, we have these monthly meetings where we actually will share difficult cases you know, and we, we don't share every one of these cases because many of them are very difficult.

We could fill the, fill a conference, every single clinic. But we do choose some cases and this is also for residents and fellows on the service. So we can just get a different perspective from different surgeons. We have a radiologist who's on these calls as well. We have a surgeon who's in the community who helps.

So there's that multidisciplinary care. And then we also talk to our fellows about, you know, feedback. You gotta, you have to give them feedback, not just in the operating room but also at the end of each case, I think that's really important. Thanks so much, Dr. Aronson. Dr. Hereford, do you have anything to to add to

this?

If you think about a fellowship, in abdominal reconstruction or in hernia repair. One thing I really think you need to differentiate is, like I had a conversation, I've had this conversation several times before, where surgeons will call themselves hernia surgeons, but then they say, well, all the, the only hernia that I do, I'll do robotic.

That's my only approach to, to hernia repair. And then what you aren't is a true hernia surgeon, you're a robotic surgeon. You know, one option is no option. That's what I say all the time. And for young people who are thinking about wanting to do abdominal reconstruction, I would say, and again, this comes from my personal perspective, so take it as that, but you want to learn the full gamut.

When you go into the operating room, this is what I perceive my plan will be, but then, you know, option a is unavailable to us, then you're going to fall back to your next option. Then you fall back to your next option. Then you can't get the fascia closed. And what do you do in that situation? And

working with someone who is, you know, that been there, done that cliche, absolutely, but learning the stepwise progression within, in the operating room, it's not just not just.

Robotic hernia repair and it's not just open hernia repair either and being able to fix an inguinal hernia, you know, you know, half a dozen different ways, you know, including, you know, then add on top of that the tissue repair and the same thing for for ventral hernias, you know, you want and again from my personal perspective.

If you want to be an expert, you want to be able to cover the whole gamut for every patient who walks in your, in your office. And one thing that's great about, like, hernia repair is that the techniques have changed. The techniques have grown. What we understand about the abdominal wall, the anatomy, everything has made, I mean, all of that, the growth of that has grown us into a specialty.

And so embrace the specialty and all that it offers if you want to, if you want to do, become a true abdominal reconstruction surgeon. That's great. I feel like as

somebody who is currently going through the training process, you know, one of the things that sticks out to me is Not just learning the technical aspects of hernia surgery, but learning the approach to caring for hernia patients, both inside and outside the operating room, but also understanding the mindset of what you're going to do before the surgery and having, you know, options A through D.

You know, are you going to be able to close the fascia? What type of release do you think you're going to be used? What would be your backup to that? What type of measure are you going to use? Where is the patient going to go post operatively? What do you need to focus on in terms of fluid management after the operation?

All of these things are really important. I think having the mentorship from people who have been around and have you know, kind of seen all the variation in hernia care over the course of time is very valuable. Another thing that, you know, I have been thinking of, and I've been doing a lot this year is video review with attendings.

So when you're in the operating room, going through with an attending surgeon, looking at what you're doing well, what you're not doing

well, and trying to really focus on how you can get better. I think that's been, you know, something that's been critical. I know that's that's something that you all do at Carolina's as well.

But kind of transitioning there. Monica, would you kind of talk to us briefly about the requirements from from a hernia surgery perspective that the American Board of Surgery has set forth? I think that'll set the stage a little bit more for the advanced training conversation. Yeah, thanks, Sully.

So briefly, I'll review the requirements for general surgery residents in hernia surgery. In order to satisfy the hernia requirements for general surgery residency as set forth by the American Board of Surgery, of the 850 required major cases, 85 fall under the hernia category. And that's essentially it.

There's no further breakdown of this number in terms of modality of repair or even hernia type. So residents are graduating with a wide range in the level of experience and complexity of their hernia training. There are also no specific requirements about clinic or the

perioperative care of the hernia patient.

And though we often assume that this non technical aspect of training just goes This does not seem to be the case in a survey conducted by the Sages Hernia Task Force and published in Surgical Endoscopy in 2015, residents themselves were surveyed on their experiences and training. The authors noted the prevalence of a see one, do one, teach one type of approach to hernia training and revealed that a system based approach to hernia care and patient outcomes were among the least discussed aspects in hernia training.

And trainees felt that this was A lacking aspects of their training. Overall, the hernia requirements in general surgery training are fairly nonspecific and shows us that there certainly is a role for advanced training in this area so that surgeons are able to tackle the most complex abdominal wall cases.

Like Dr. Henniford mentioned previously, hernia never will nor should be a complete specialization, but there are instances where the level of complexity does benefit from more focused, clearly defined and specialized training. Great,

Monica. So I think that transitions to the next topic, which I'll touch on briefly, which is fellowship.

Hernia and abdominal wall surgery. So as Dr. Hannaford alluded to earlier, I mean, we have been training hernia surgeons here for nearly 25 years and there have been other places around the country doing the same. However, this year is a special year in the sense that it marks the first year where the fellowship council, which is an association of program directors and special specialty societies charged with overseeing fellowship training programs, specifically minimally invasive surgery, hepatobiliary surgery and colorectal surgery, as well as others, has actually granted a designation in abdominal wall reconstruction.

And so this year, there are six programs that are participating on kind of a piloted approach. But there are other designations that have previously existed, such as those in foregut surgery, bariatrics, and flexible endoscopy. And so I think it's worth reviewing some of the requirements for these

participating programs, which I presume will expand in the future the requirements for the abdominal wall reconstruction designation or developing collaborations with surgeon members from both the American Hernia Society, as well as SAGES.

And so there are a couple of components to this abdominal wall reconstruction designation. And the first has to do with case volume and case volume and different types of hernia repair. So 100 core procedures, 30 of which are inguinal or groin hernias. And there is a minimally invasive component to this.

Half of those should be completed in an M. I. S. fashion, and then there's a requirement. Mid-size and large ventral hernias. And there are 30 required mid-size hernias, which are designated as three to 10 centimeters and then 25 over 10 centimeters. In addition to that, there are is a requirement for the repair of atypical hernias.

Those include things like parastomal hernias, subxiphoid hernias, and flank hernias. And then the

Fellowship Council is also in the process of developing a hernia curriculum which is not yet publicly available, but will presumably touch on the perioperative care of the hernia patient as well.

And then there is a necessary documentation of competency in five of the eight EPAs that have been set forth by the Fellowship Council. At the end of the One's training. There is no additional examination that is mandated, and there is no separate board certification as there is in other parts of the world.

And Monica will touch on here. Briefly. I anticipate that since this is the 1st year, the expectation is that these requirements will change somewhat over the coming years as case numbers are evaluated and the need for certain types of repairs or is more further evaluated. In addition to the programs that I mentioned, there are still training programs that exist outside of the Fellowship Council paradigm that focus on training herding insurgents and do

so, in a very high level.

Those exist around the country for example, Columbia University, Dr. Henniford Hood. Mentioned Yuri Novitskiy earlier, who's the past president of the American Hernia Society. Dr. Beliansky also has a training program at Anna Rundle. So, there are many different ways to go about getting proper exposure to hernia surgery in the country.

Monica, would you just kind of touch base on how the training paradigm that we are developing, I guess, in the United States compares to that with Europe? Absolutely. So the recognition of a formal designation of an abdominal wall surgery and fellowship training is an idea that was seen in Europe before the United States, the European Board of Surgery in conjunction with the European Union of Medical Specialists introduced the idea of fellowship training and certification in 2019.

And the idea is that fellowship training is available after the completion of six years of general surgery training and fellowships are one to two years and focus specifically in hernia surgery. The

training must take place under at least two or more surgeons and follows a very specific syllabus set forth by the European board, which focuses not only on operative volume, but on specific anatomy and knowledge components in hernia, as well as perioperative management.

A total of 300 operations must be performed in three principal categories, including inguinal, primary ventral, and incisional hernias. And once candidates have fulfilled the requirements for all of these areas, they can then apply to sit for the exam, which consists of a written portion of 100 multiple choice questions over four hours, and also a structured clinical exam that consists of six stations over the course of an hour that evaluates judgment and clinical decision making.

An overall passing score for both parts together is 75 percent in order to earn the fellow European Board of Surgery and Abdominal Wall Surgery

Certificate. Those are pretty stringent requirements, but I think they reflect the fact that, you know, there is so much nuance in developing to become a hernia specialist.

And so, my anticipation is that you know, the more, people that are training hernia surgeons in the United States. Hopefully the requirements evolve to, to mirror those a little bit more. I definitely think that, you know, having 300 cases minimum and then taking two separate exams following your advanced training in hernia surgery certainly prepares you to go and tackle a lot of the complex cases early on in your career.

Dr. Henford, we talked about the kind of evolution of training people. You know, one thing that I see is a challenge in hernia surgery now is that there are just so many ways to do a particular procedure. It seems like every week that we read a journal, there's a new technique that's being published, you know, with promising data.

How do you, how do you

mitigate that challenge with just so much? There's so much out there now. Thanks, Sully. Before I get into my piece of this that you just asked me, you know, I think it's important that the paper that you and Brittany Mead wrote in an assessment of becoming a hernia specialist and the training involved.

Can you talk about that for one second before I jump in here? Yeah, I think, so, Dr. Meade who was a fellow that graduated last year, she's now attending at Rush University of Chicago. Her and I wrote a prospective piece that just got published in Surgery that focused on really, you know, what we should be doing.

Focusing on as trainees. And so we talked about the different requirements both here in the United States and abroad. And really, we're kind of advocating for a push to make hernia include a lot of the things outside of the operating room. So focusing on outcomes, focusing on preoperative optimization, focusing on post operative management of the hernia

patients specifically things like physical therapy and rehabilitation and really trying to push for more stringent requirements.

One of the main points of that paper was that, you know, as trainees, sometimes we actually want more and we want to be more stringently evaluated before. We're set free. And I think in hernia specifically, there's a lot of utility of pushing to have more information, more requirements, and more training as the complexity of the specialty grows.

Yeah, terrific. As far as challenges in training abdominal reconstruction surgeons, You know, one of the things I would want to mention is you look at the growth and you talk about the growth of the, the literature over the last, and I, when I look back at it, it's like 16 years beginning, if you go back 16 years ago, 16 years ago to last year, there's been a fourfold increase in the number of papers that have been written about hernia repair.

And not all of them are all great papers, and that is the peer

reviewed literature, so that's, you know, it's good that it's peer reviewed. But if you look at the passion around hernia repair, that has driven a lot of its growth. And there's a, a famous philosopher, English philosopher from the 1800s, Chesterson, who said, you know, Men did not love Rome because she was great.

Rome was great because they loved her. And I think this passion around hernia repair, this drive around hernia repair has been extremely helpful. And it has pushed hernia repair to the forefront, and if you look at most academic institutions that at least the ones that I've talked to, and of course that may add some bias to it, they're looking to add specialization in the bowel reconstruction.

And so therefore the training needs to step up. And it's not just what happens in the operating room as we've made mention in previous Behind the Knife episodes and also in this one, and learning the preoperative adjuncts, learning about Botox, learning about weight loss, you know, what's important in the ORs.

You know, if you, if you have an

infection, you increase your chance of failure by more than threefold. If you don't get the fascia closed, multiple articles, including our own showing a recurrence rate seven times higher. So you can impact that. In preoperative, in your preoperative consultation with patients being motivating patients and not taking the stance, well, they, they're all not going to lose weight and they're not going to, they're not going to keep it off.

We've actually demonstrated that's not true. And more than 80 percent of people will keep off more than half their weight. And 47 percent of people will continue to lose weight even three years out, but using, you know, learning the preoperative adjuncts is super important. How do you tee yourself up for success?

You come in fully, fully prepared. You mentioned like the growing number of techniques, you have to know all of these. You don't. And one, but one thing I would say is, you know, if you're going to do something new, make sure you completely understand it. And I talked to the fellows about like, you have to apply the field a lot.

You know, you have to have, you know, very

fertile ground, you know, before you start taking on something else that's new. One of the issues with like transversus abdominis relation, and I saw a patient again yesterday, came from an academic institution where they had transected the simulinaris in a, in a, in a tar.

If you look at the paper that Yuri Novitskiy wrote about tar and about training, You know, you have surgeons who says I can learn a tar over 60 percent of the surgeons, 65 percent actually, and there's over 250 surgeons said I can learn a tar in 0 to 10 cases, and 25 percent of them said they learned tar online.

You know, I think we have to be very careful with that, and you don't have to, I mean, You need to have lots of tools in your toolbox, but you need to be trained if you're going to be a true abdominal reconstruction surgeon. Absolutely. And as an abdominal reconstruction specialist, we have to understand that a three centimeter defect of someone with a BMI of 20 is often approached very differently than someone with a BMI of 47.

Taking this case by case,

understanding mesh in the operating room. You know, we talked about, Sully, about like, you get there, you can't get the fascia closed. Okay, what's next? Okay. Understanding the, the complexity of the patient, as far as like their, their chance of developing wound related complications, understanding what previous surgeries they've had, understanding the perhaps the contamination level in this case, understanding what mesh you're going to place with that and rolling that up.

into what the possible complication rates might be, what the possible complications might be, how severe they might be, the, and then what the patient wanted before surgery, being able to blend all that together for decision making in the operating room, now you're, now you're becoming a specialist. You know, I think it's, it's, are super important.

Absolutely. And I would hope that, you know, specialist, you know, being able to track your own outcomes, being able to see your own deficits, you know, to make real progress, you really need an honest report card. And

I'll just tell you as a young surgeon, you want to, you know, the complications hurt my feelings.

You know, I wanted to hide my complications. Now, as an, as a more senior person in this, in this world of surgery, I want to learn from them as much as possible. That's fantastic, Dr. Hunter Ferguson. Definitely an evolution kind of in showing the growth of this institution over time. Dr. Argenstein, we'll wrap it up with you.

Anything else that you have to add about the way that you see the future of training in hernia surgery going over the next few years? As well. Yeah, I think the future of hernia surgery is really exciting. I'm excited to be a MIS surgeon who's trained in hernia. I want to make a plug for the American Hernia Society because it's only 25 for residents and fellows to join.

And you really get a lot for this in addition to having access to the full web library that has over 80 expert lectures recorded on it on different topics in

hernia. You really it's a community. We're doing a lot of different things from focus practice designation to putting on a lot of courses for both residents and fellows and attending surgeons.

So I do think it's a very exciting time. I think I touched on this a little bit as far as the future with hernia research, and I think we. definitely are lacking high quality data in hernia. And that's something that we need to for a problem that we fixed 400, 000 times just on the ventral hernias in the United States.

We have to have papers that have more than a hundred patients. And, you know, we, we really have to start basing our guidelines more on, on more patients and more data. So I think I'm hoping that the future of hernia is really going to be bright and it's going to be really good. Awesome. Thanks. I can see.

I know that I can speak for all of us and saying that we're very much looking forward to next year's a just meeting in Nashville. We know that you'll make it a make it a memorable 1. so now for our quick hit section advanced

training and hernia repair is a relatively recent development that is rapidly evolving.

Hernia requirements for general surgery residents are fairly minimal and non specific. This year marks the first year that there is advanced training designation in abdominal wall surgery and that comes from the fellowship council. There are a number of challenges in training hernia surgeons, which include the heterogeneity of cases and the increasing number and type of repair that are offered out there.

The aim of abdominal wall training should be to focus on the entire spectrum of hernia care, including pre and post op management of the hernia patient. In addition to focus on surgical technique. So once again, this is the behind the knife hernia team based at Carolina's medical center, reminding you to dominate the day.

Thank you very much.