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Behind The Knife: The Surgery Podcast

Behind The Knife: The Surgery Podcast
Behind The Knife: The Surgery Podcast
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  • Clinical Challenges in Robotic Bariatric Surgery: The Robot is Here to Stay!
    Join us as we dissect the use of robotics in bariatric surgery – where precision meets programming, and the scalpel gets a software upgrade. Video Clip Link: https://app.behindtheknife.org/video/clinical-challenges-in-robotic-bariatric-surgery-the-robot-is-here-to-stay This videos includes: - Robotic RYGB - Robotic Sleeve Gastrectomy - SADI: Single Anastomosis Duodenoileostomy Hosts:  - Matthew Martin, trauma and bariatric surgeon at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California) - Adrian Dan, bariatric and MIS surgeon, program director for the advanced MIS bariatric and foregut fellowship at Summa Health System (Akron, Ohio) -  Crystal Johnson Mann, bariatric and foregut surgeon at the University of Florida (Gainesville, Florida) - Katherine Cironi, general surgery resident at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California) Learning objectives:  Strengths of the robot:  Surgical robots are at the forefront of technology and continue to improve with detailed, precision cameras and the ability to remove baseline tremors Allows for smooth movements, fine dissection, and precise tissue handling  Ergonomics are more advantageous to the surgeon when compared to laparoscopy Weaknesses of the robot: The loss of haptic feedback can be challenging for surgeons early in their learning curve Emphasis on surgical robots means some trainees may be losing exposure to laparoscopic techniques Longer operative time when working robotically, and more time under anesthesia for the patient  Increased cost for robotic surgery  Outcomes data:  Mixed data from the MBSA QIP database (metabolic and bariatric surgery accreditation and quality improvement program) The most recent study looked at 824,000 patients from 2015-2022 who had a sleeve gastrectomy or RNY gastric bypass, either laparoscopically (lap sleeve 61%, lap RYGB 24%) or robotically (robo sleeve 11%, robo RYGB 4%). Robotic sleeves were reported to have higher complication rates compared to laparoscopy, seen as higher overall morbidity and an increased rate of leaks  While the robotic RYGBs have lower overall complications, including decreased morbidity and bleeding. Robotic RYGB can be especially advantageous with revisional surgeries when compared to lap.   Setting up for success Train your eyes to determine tension on tissue, since there is no haptic feedback Learn how to assist yourself (manipulating the camera and effectively utilizing the fourth arm) Understand how techniques of the surgery change when doing it robotically, as compared to laparoscopy  Experienced operating room team  When learning, recommend putting all cases feasible on the robot (including easier cases), to master the straightforward cases before moving to technically challenging revision cases. Don’t hesitate to add an additional trocar or assistant port when needed  Education in Robotic learning  Learning by observation/mirroring – ex: robotic bilateral inguinal hernia (mirroring the attending/instructor)  Easy for the attending/instructor in the case to switch instruments seamlessly, then give them back intermittently at the appropriate time  Helpful when the attending annotates the screen to depict where to go  Data-driven teaching tools on the Davinci system  Tips for robotic sleeve gastrectomy:  Of the robotic bariatric surgeries, sleeve gastrectomy is most similar to its laparoscopic procedure 30-40 degrees of reverse Trendelenburg Liver hammock stitch instead of a liver retractor (one less trocar), which makes a total of 4 trocars needed for the case Green staple load for the first firing, then the rest are typically blue loads Mixed opinions on reinforced staple loads versus non-reinforced staple loads and oversewing the staple line (discussed cost-benefit)  Tips for robotic gastric bypass:   Watch videos from colleagues to learn what they do Gastric bypass is a multi-quadrant surgery; thus, you must set yourself up for success so that your arms are not fighting when moving through different quadrants  A size 12 trocar on the left can make the formation of  the gastric pouch easier GJ and JJ anastomosis formed with a linear fire, then a two-layer closure with absorbable barb suture Don’t forget to close the mesenteric defect (non-absorbable braided suture) Tips for robotic DS and SADI:   If doing a duodenal anastomosis hand-sewn, then recommend planning the exact number of sutures and locations of each for ease Hand-sewn anastomosis can have less bleeding and fewer strictures for patients, and is completed in a much more seamless fashion with the robot   Future of Robotics  Haptic feedback Integrated visual overlays to identify anatomical structures/serve as an intraoperative map Artificial intelligence integration  Telesurgery – ex, small surgical robot deployed to space  Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen
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  • Clinical Challenges in Vascular Surgery: The Risk & Reality of EVAR Complications
    It’s 2 a.m. The on-call resident’s voice is shaky. The CT shows an 18cm abdominal aortic aneurysm with a Type 1B endoleak. There’s gas in the sac, fluid in the belly, and the patient has a defibrillator on both sides of his chest. Is it a rupture? A graft infection? An aortoenteric fistula? All of the above? You’re the vascular surgeon, what do you do?  This episode dives deep into decision-making when EVAR fails, when infection strikes, and when the patient might not survive a definitive repair. Let’s talk about what happens when clinical textbooks meet real-world chaos. Hosts: ·      Christian Hadeed -PGY 4 General Surgery, Brookdale Hospital Medical Center ·      Paul Haser -Division chief, Vascular Surgery, Brookdale Hospital Medical Center ·      Andrew Harrington, Vascular surgery, Brookdale Hospital Medical Center ·      Lucio Flores, Vascular surgery, Brookdale Hospital Medical Center Learning objectives: · Understand the clinical implications and management of late EVAR complications, including Type 1B endoleak and aortoenteric fistula. · Explore the decision-making process in critically ill patients with multiple comorbidities and infected aortic grafts. · Compare endovascular vs open surgical approaches in the setting of infected AAA, and when each is appropriate. · Recognize the role of multidisciplinary collaboration in complex vascular cases. · Discuss the ethical considerations and goals-of-care planning in high-risk, potentially terminal vascular patients. · Highlight the importance of long-term surveillance after EVAR and the consequences of noncompliance. References ·       Karl Sörelius et al.Nationwide Study of the Treatment of Mycotic Abdominal Aortic Aneurysms Comparing Open and Endovascular Repair.Circulation. 2016;134(22):1822–1832. PubMed: https://pubmed.ncbi.nlm.nih.gov/27799273/ pubmed.ncbi.nlm.nih.gov+15pubmed.ncbi.nlm.nih.gov+15researchgate.net+15 ·       PARTNERS Trial (OVER Trial).Outcomes Following Endovascular vs Open Repair of Abdominal Aortic Aneurysm: A Randomized Trial.JAMA. 2009;302(14):1535–1542. PubMed: https://pubmed.ncbi.nlm.nih.gov/19826022/ pubmed.ncbi.nlm.nih.gov+6pubmed.ncbi.nlm.nih.gov+6jamanetwork.com+6 ·       B.T. Müller et al.Mycotic Aneurysms of the Thoracic and Abdominal Aorta and Iliac Arteries: Experience with Anatomic and Extra-anatomic Repair in 33 Cases.J Vasc Surg. 2001;33(1):106–113. PubMed: https://pubmed.ncbi.nlm.nih.gov/11137930/ sciencedirect.com+5pubmed.ncbi.nlm.nih.gov+5periodicos.capes.gov.br+5 ·       Chung‑Dann Kan et al.Outcome after Endovascular Stent Graft Treatment for Mycotic Aortic Aneurysm: A Systematic Review.J Vasc Surg. 2007 Nov;46(5):906–912. PubMed: https://pubmed.ncbi.nlm.nih.gov/17905558/ researchgate.net+15pubmed.ncbi.nlm.nih.gov+15pubmed.ncbi.nlm.nih.gov+15 ·       Hamid Gavali et al.Outcome of Radical Surgical Treatment of Abdominal Aortic Graft and Endograft Infections Comparing Extra‑anatomic Bypass with In Situ Reconstruction: A Nationwide Multicentre Study.Eur J Vasc Endovasc Surg. 2021;62(6):918–926. PubMed: https://pubmed.ncbi.nlm.nih.gov/34782231/ pubmed.ncbi.nlm.nih.gov+6pubmed.ncbi.nlm.nih.gov+6diva-portal.org+6  Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen
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  • Clinical Challenges in Hepatobiliary Surgery: Necrotizing Pancreatitis, Time to Step Up!
    In the corner of the ICU, on multiple pressors, distended, oliguric, and intubated you’ll find the necrotizing pancreatitis patient. Sounds intimidating, but with the persistence, patience, and the proper care these patients can make it! In this episode from the HPB team at Behind the Knife listen in as we discuss the Step-Up approach, when to surgically intervene, various approaches to pancreatic Necrosectomy, and additional aspects of the multidisciplinary care required for the successful treatment of necrotizing pancreatitis.  Hosts Anish J. Jain MD (@anishjayjain) is a current PGY3 General Surgery Resident at Stanford University and a former T32 Research Fellow at the University of Texas MD Anderson Cancer Center. Jon M. Harrison is a 2nd year HPB Surgery Fellow at Stanford University. He will be joining as faculty at the Massachusetts General Hospital in Boston, MA at the conclusion of his fellowship in July 2024.    Learning Objectives ·      Develop an understanding of the severity of necrotizing pancreatitis and the proper indications to surgical intervene on this often-tenuous patients.  ·      Develop an understanding of the Step-Up approach and key aspects (reimaging, clinical status, physiologic status, etc.) that determine when to “step-up” treatment for patients with necrotizing pancreatitis. ·      Develop an understanding of long term sequalae and complications associated with necrotizing pancreatitis and operative management ·      Develop an understanding of multidisciplinary care and long-term follow-up necessary for adequate treatment of patients suffering from necrotizing pancreatitis. Suggested Reading Maurer LR, Fagenholz PJ. Contemporary Surgical Management of Pancreatic Necrosis. JAMA Surg. 2023;158(1):81–88. doi:10.1001/jamasurg.2022.5695 https://pubmed.ncbi.nlm.nih.gov/36383374/ Harrison JM, Day H, Arnow K, Ngongoni RF, Joseph A, Aldridge T, Wheeler KJ, DeLong JC, Bergquist JR, Worth PJ, Dua MM, Friedland S, Park W, Eldika S, Hwang JH, Visser BC. What's Behind it all: A Retrospective Cohort Study of Retrogastric Pancreatic Necrosis Management. Ann Surg. 2024 Sep 3. doi: 10.1097/SLA.0000000000006521. https://pubmed.ncbi.nlm.nih.gov/39225420/ Harrison JM, Visser BC. Not Dead Yet: Managing the Abdominal Catastrophe in Necrotizing Pancreatitis. Pancreas. 2025 May 20. doi: 10.1097/MPA.0000000000002512. https://pubmed.ncbi.nlm.nih.gov/40388698/ Harrison JM, Li AY, Sceats LA, Bergquist JR, Dua MM, Visser BC. Two-Port Minimally Invasive Nephrolaparoscopic Retroperitoneal Debridement for Pancreatic Necrosis. J Am Coll Surg. 2024 Dec 1;239(6):e7-e12. doi: 10.1097/XCS.0000000000001152. https://pubmed.ncbi.nlm.nih.gov/39051721/ van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, van Goor H, Schaapherder AF, van Eijck CH, Bollen TL, van Ramshorst B, Nieuwenhuijs VB, Timmer R, Laméris JS, Kruyt PM, Manusama ER, van der Harst E, van der Schelling GP, Karsten T, Hesselink EJ, van Laarhoven CJ, Rosman C, Bosscha K, de Wit RJ, Houdijk AP, van Leeuwen MS, Buskens E, Gooszen HG; Dutch Pancreatitis Study Group. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010 Apr 22;362(16):1491-502. doi: 10.1056/NEJMoa0908821. https://pubmed.ncbi.nlm.nih.gov/20410514/ Bang JY, Arnoletti JP, Holt BA, Sutton B, Hasan MK, Navaneethan U, Feranec N, Wilcox CM, Tharian B, Hawes RH, Varadarajulu S. An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis. Gastroenterology. 2019 Mar;156(4):1027-1040.e3. doi: 10.1053/j.gastro.2018.11.031. https://pubmed.ncbi.nlm.nih.gov/30452918/ Zyromski NJ, Nakeeb A, House MG, Jester AL. Transgastric Pancreatic Necrosectomy: How I Do It. J Gastrointest Surg. 2016 Feb;20(2):445-9. doi: 10.1007/s11605-015-3058-y. https://pubmed.ncbi.nlm.nih.gov/26691148/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen
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  • Intern Bootcamp: Dominate Intern Year
    RE-RELEASE This was first published in 2023 but it's so good we are running it back! Buckle up, PGY-1’s! Intern year is starting whether you’re ready or not. Don’t fret, BTK has your back to make sure you dominate the first year of residency.  In this last episode of the intern bootcamp mini-series, we’ll talk about tips & tricks as well as good habits to establish in order to dominate intern year. Hosts: Shanaz Hossain, Nina Clark Tips for New Interns:  GENERAL TIPS FOR SUCCESS ON THE WARDS Spend time with the patient! Trust, but verify. Be kind to everyone. Stay humble. Be flexible. Seek and apply feedback. HOW TO LEARN IN THE OR Double scrub as many cases as you can. Write down/record everything after a case. MAINTAIN YOUR PERSONAL SANITY Figure out your stress outlets and what brings you joy. Decompress after work. Maintain work/life boundaries. Keep in touch with loved ones. Vacations are meant for relaxation.Repeat after me: NO WORK ON VACATION! Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more. If you liked this episode, check out our new how-to video series on suture and knot-tying skills – https://behindtheknife.org/video-playlists/btk-suture-practice-kit-knot-tying-simulator-how-to-videos/
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  • Intern Bootcamp: Scary Pages
    RE-RELEASE This was first published in 2023 but it's so good we are running it back! Buckle up, PGY-1’s! Intern year is starting whether you’re ready or not. Don’t fret, BTK has your back to make sure you dominate the first year of residency. Today, we’re hitting the wards and tackling some of the scary clinical scenarios you will see as an intern. Hosts: Shanaz Hossain, Nina Clark Tips for new interns: THINGS TO REMEMBER ·       BREATHE. In most cases, you have a little bit of time – at least enough to take a breath and calm down outside the room before heading into an emergency. Panic doesn’t help anybody. ·       See the patient. Getting a bunch of pages? Worried about someone? Confused as to what’s going on? Go see the patient and chat with the bedside team. ·       Know your toolbox. There are a ton of people around who can help you in the hospital, and knowing the basic labs/imaging studies and when to use them can help you to triage even the sickest patients. ·       Load the boat. You’ve heard this one from us all week! Loop senior level residents in early. HYPOTENSION ·       Differential: measurement error, patient’s baseline, and don’t miss – SHOCK.            - Etiologies of shock: hemorrhagic, hypovolemic, ·       On the phone: full set of vitals, accurate I/Os, ·       On the way: recent notes, PMH/PSH including from this hospital stay, and vitals/I&Os/studies from earlier in the day ·       In the room: ABCDs – rapidly gives you a sense of how high acuity the patient is ·       Get more info: labs, consider imaging, work up specific types of shock based on clinical concern. ·       Initial management: depends on etiology of hypotension; don’t forget to consider peripheral or central access, foley catheterization for close monitoring of urine output, and level of care HYPOXEMIA ·       Differential: atelectasis, baseline pulmonary disease, pneumonia, PE, hemo/pneumothorax, volume overload ·       On the phone: full set of vitals, amount of supplemental oxygen required and delivery device, rate of escalation in oxygen requirement ·       On the way: review PMH/PSH, known injuries (known hemothorax/pneumothorax? Rib fractures? Chest tubes in already?), risk factors for DVT/PE, review I/Os for evidence of volume status, vitals and labs for evidence of infection ·       In the room: ABCDs, pulmonary and cardiac exam, volume status exam ·       Get more info: basic labs, ABG if worried about oxygenation, CXR, consider bedside US of the lungs/heart, if high suspicion for PE consider CTA chest ·       Initial Management: supplemental O2, higher level of care, consider intubation or other supplemental oxygenation adjuncts, additional management dependent on suspected etiology ·       ABG Vs VBG (IBCC): https://emcrit.org/ibcc/vbg/ ALTERED MENTAL STATUS ·       Differential: stroke, medication effect, hypoxemia or hypercarbia, toxic or medication effect, endocrine/metabolic, stroke or MI, psychiatric illness, or infections, delirium ·       On the way: review PMH/PSH, recent notes for evidence of altered mentation or agitation, or signs hinting at above etiologies ·       In the room: ABCDs, focal neuro deficits?, alert/oriented? Be sure the patient’s mental status is adequate for airway protection! ·       Get more info: basic labs, blood gas/lactate, CT head noncontrast if concerned for stroke. ·       Initial management: rule out above; if concerned about delirium, optimize sleep/wake cycles, pain control, and lines/drains/tubes. OLIGURIA ·       Differential: prerenal due to hypovolemia or low effective circulating volume, intrinsic renal disease, post-renal obstruction ·       On the phone: clarify functional foley or bladder scan results, full set of vitals ·       On the way: review PMH/PSH, known injuries (known hemothorax/pneumothorax? Rib fractures? Chest tubes in already?), risk factors for DVT/PE, review I/Os for evidence of volume status, vitals and labs for evidence of infection ·       In the room: ABCDs, confirm functioning foley catheter ·       Get more info: basic labs, urine electrolytes, consider fluid challenge to evaluate responsiveness, consider adjuncts including renal US ·       Initial management: typically consider IVF bolus initially, but if patient not volume responsive, don't overload them -- look for other etiologies! TACHYCARDIA ·       Differential: sinus tachycardia (pain, hypovolemia, agitation, infection), cardiac arrhythmia, MI, PE ·       On the phone: full set of vitals, acuity of change in heart rate, updated I/Os ·       On the way: Review PMH/PSH, known cardiac history, cardiac and PE risk factors, volume resuscitation, signs concerning for infection, updated I/Os ·       In the room: ABCDs, cardiac/pulmonary exam, evaluate for any localizing signs for infection ·       Get more info: basic labs, EKG, consider CXR, troponins ·       Initial management: depends heavily on etiology Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more. If you liked this episode, check out our new how-to video series on suture and knot-tying skills – https://behindtheknife.org/video-playlists/btk-suture-practice-kit-knot-tying-simulator-how-to-videos/
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Behind the Knife is the world’s #1 surgery podcast.  From high-yield educational topics to interviews with leaders in the field, Behind the Knife delivers the information you need to know.  Tune in for timely, relevant, and engaging content designed to help you DOMINATE THE DAY! Behind the Knife is more than a podcast.  Visit www.behindtheknife.org to learn more.  
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