Chapters Transcript Video Trends to watch: Predictive analytics, CT scans, AIB. - Todd Heniford, M.D. I'm gonna have Doctor Hereford come up and talk a little bit about trends in hernia repairs. Very good. So I'll say one thing. So the consideration of operating on patients who? Yeah, I think I think we got it. Thanks so much. Operating on patients who who are smoking, I mean that it's just a big problem. And I'm gonna show a couple of slides here in a minute about about the growth in hernias in the need to actually move operations along. And so when we talk about the tale of the, uh, Piri operative CT scan and then using it as a tool for this, but I you know, I did like it's kinda like rubbing the rubbing the the magic lamp with the genie, you know? So I did it once before, so let's just see if I can do it again. Yeah, At least I didn't put bourbon up there for me. All right, So and this is a This was for Cobb right here. When you talk about smoking marijuana and those of you from Colorado and the like, Mhm. So I just can't help myself. Yeah. I mean, no one else may laugh but I laugh. And so So why the c t scan? Of course it's ubiquitous. I mean, it's certainly reproducible. I mean, we have patients who come from very small communities with small hospitals. They all have CAT scans. They can get their CAT scan. They can actually actually shipped this cat scan to it. It's very mobile, very transportable, online and the like. And the other thing I stole. This slide from Will Cobb as well is a you know, it's just like my old football coach used to say that I and this guy doesn't lie. When you look at the film of the game, you can say what you did. But the But the film tells the truth, and and and and indeed, the CAT scan prepares me to take care not only the super complex patients but your standard patient I mean to one of the most important things in this is to look at it yourself. And I think most of the surgeons who actually fix hernias do that, but don't depend on the radiologist. And there's really good data that demonstrates if a radiologist looks at it and says there is a CAT scan assuming there is a hernia. Almost always, they are correct, but they frequently. If you just say Syncopation for an abdominal ct and they don't say it's a hernia, it's the the prediction of it. Not being a hernia in a patient is actually really quite low unless you talk to the radiologist. And then, of course, you'll get things like this, and our radiologist calls us to digest Asus, and it's absolutely a recurring hernia, no question, functionally a recurrent hernia, and we're gonna operate on this patient. But but things like this calling it a diarist, Asus and again, you know, even looking at anymore hernias. It's even worse because they're looking for cancer. They're looking for aneurysms are looking for all the important stuff, and we're just hernia surgeons. So it's super important to look at them yourself. And there is a paper written on this by, uh, some friends of ours from from England, if you're if you're so interested. So also looking at the defect, how big is the defect? And one of the important things is like for me is where's the defect located? Am I gonna miss other defects? So defects like this right on the iliac crest. These are difficult to fix. There's no fashion of so two. There's no muscle there. And two, how do you fix these? So this this is going to get me ready to put bone anchors in patients pre honorably. I'm gonna know that I'm going to use bone anchors in these folks. We've been highly successful, and so we used. So we'll use a double arm bone anchor ones for the mesh and want to try and future the future. The muscle back down to the fashion back down, down to the iliac crest. But it gets me ready, especially in an atomic locations, of course. And then how big is the defect? How much is on the outside looking at your previous abdominal failures, like Helped me prepare for these patients showed this patient earlier on this patient with a failed tar. It also helps me when you look at this patient helps me functionally talk to the patient functionally about what they're gonna have after their operation. Your rectus muscles are never going to work again. That's not going to happen. Like doing core exercises for you. I mean, that's just like I wouldn't do them. You're not going to make this better. So functional results and talking because of the patient. If you don't tell them functionally your your rectus muscles are not gonna recover, they may expect that they're gonna They should recover, but they don't other considerations. It's like sometimes it's questionable. Like you read an operative note. You know, You know what is in this operative note? I don't really understand like this patient was supposed to have And they a, uh, an operation where the mesh was placed inside her abdomen, developed a complication, had to have part of the mesh resected only had one hernia repair ended up with a skin graft. And let me tell you, we've all had complications. There's no questions. All had infectious complications. But if you start looking at this and start looking at this cat skin, if you actually look at you start looking out here. It's like attack. There's attack on the outside of the abdominal wall and then you look at it from from here and you start to see these tax lining lining outside the abdomen. Here it totally doesn't match what's in the operative note. So I know that that plane, that subcutaneous plane has been violated. And I know I'm gonna find something there, and it's probably gonna be meshed. Otherwise, why would it be tax outside the abdomen? So anyway, helps me prepare absolutely patients like this. This patient was supposed to have had a previous external bleak release. And there's the external oblique is completely intact. The fact is completely intact. So I now know that doing a an external bleak release is back on the table. It helps me get prepared. Absolutely. And so I know you can see that even the fashion there is completely intact. You know, this is a patient of mine had to put a lightweight polypropylene mesh in there. The patient completely blew out, blew through this and, well, you guys have seen this. And and I mean, heck, I'd blame you entirely when you're our fellow for writing that paper the most, I'll just tell you. Like like trying to make ourselves better. When Dr Cobb was a fellow, that was 16 or 17 years ago, something like that. And and we did a big study looking at lightweight polypropylene mesh. I was a huge advocate because less infect herbal, less mass less inflammation. Pig Study 5.5 months and reason we did it. We did many pigs, but the mini pigs turned into hog. So we stopped the study at 5.5 months because we were not gonna be able to get him back on the O. R table in the in. The very, um it worked great the problem, however, As after about 19 months or so, there's a divergence between the stronger measures in the lightweight mesh. And then it fractures and we get recurrences. But again, and then looking for, like, super badness, things like these crystals and infections and this patient that we helped take care of. Uh, that came in and she had a an outside institution had an only mesh. We thought we fixed this. We drained it, would put a wound back on it. And then, of course, getting us ready to go back in. And anyway, I got lots of bad. And so you can like seeing message growing inside the intestine and then preparing for infection. All of these people, all the badness And how about like, pain? You examine patients who have pain after eventual hernia repair. And, uh, their internist sends his patient and like you examine the patient. I feel no hernia. But if you look at this only mesh. The mess is still intact. The fascist separated. You get the intestine or the abdominal contents between the mesh and the abdominal wall, and but you can't palpate it, palpate like instead of saying, you know, you don't have a hernia recurrence and go live your life, they can't scan actually super helpful. And then, like, you know, Ms Mack, uh, their symptoms looking at what their symptoms are and looking for badness. If you look at this lady, she had a history of trauma. She did have a ventral hernia. And so one of the things that I do, I do a lot of a softail surgery, and I do hernia repair. And one of the things that I always do is that I am a quality of life. Doctor, what's your worst problem? What is your worst symptom? What do you want me to fix for you? And I asked this lady obvious mental honey after laparotomy, she said, My worst problem is my shoulder pain in my chest pain on my left side. So you pull up the cat scan and you see that she's actually got a dying from an old diaphragmatic injury. It has a kidney up in her left chest. So we actually fix that and we fix your ventral hernia patients like this who have who have plates on their pubis and things like that. Getting ready for these operations Absolutely can skin is super helpful. And this is that patient I was talking about there. Okay, the next one and a patient with pelvic pain like, ma'am, what is the worst problem that you have? You know, she has pelvic pain and she ends up having a uterine cancer. And this CAT scan was actually an outside cat scan. It's got a uterine mass outside CAT scan that we reviewed this and this cat scans like, four months old, and she had no idea matching up their symptoms with the CAT scan and why I'm actually as a quality of life, Doctor, why I'm there. Patients with cirrhosis, Of course. That's why we got invented compatibility. Surgeons. I would just say that out loud, but getting them ready for an operation. I don't operate on patients electively with cirrhosis that they have. If they have, a lot of societies will have to get them cleaned up. And you can see the changes in this lady and you can see her umbilical peri umbilical hernia is actually from a laparotomy incision after we get her. Uh, and I'll say we again get her Society is under control this period. Biblical hernia doesn't bother anymore. She did have anymore, honey, and we all we did was fix her anymore hernia and and did it under local anesthesia. And then you can assess for, like, things like Sarko, Sarko Pena, and, uh, and other and other issues. And then, of course, you get confirmed non starters And you can see this guy. And so he sent to us. He's got a massive hernia. He's got a colostomy. He actually found a cancer about colon cancer about 10 cm inside his colostomy there. But of course, if you look at his abdominal wall, what are you gonna do with this? He's got no intestine inside his abdomen. So if you're gonna take that out, what am I gonna do with it? And so you get your colorectal surgeons involved, and we end up not operating on him. And until he until he lost some weight and then again confirming nonstarters as the guy from Kentucky just outside Lexington. And so he comes in and so and he is morbidly obese. And when you start looking at this, I've never seen someone's being a cave trying to blow outside someone's abdomen. I mean, he's got like, kidneys outside. He's got his almost all of his liver on the outside, and then you just keep looking down as you come towards the bottom down there and you're just very thankful that his rectum comes back in, because then I wouldn't have known what to do with this. But anyway, and then otherwise, as far as like doing a final pre checked prior to surgery. And this is a patient who? The patient, the surgeon patient, Hurry up patient. Why certainly signed the consent for Donald? Pretty repeatable. I didn't read their previous note, didn't look at the CAT scan, fix the ventral hernia and forgot about their flying cornea, and the patient is mad as a hornet and then come to us for us to fix a plank hernia and then the final pre check. And we do this in Jannah. Does this and sees me do this all the time. Sometimes the CAT scan is just worth it. It's worth the price of the cat scan to tell me where to get in the abdomen safely. And you can see as you walk down in this patient the getting, uh, this one walk down this you can see that the, uh the intestine lining the skin graft as you come down and then you can see the place to get in is down low where there's where the fat. Is there a couple of other things about cat scans? Looking at this is again some work that Katie Slaughter is done. You know, we can look at the essentially the dimensions of the hernia, the subcutaneous fat in the intra abdominal intra abdominal contents, and start to make actually some real suggestions of of our care using objective data. And so we've been pushing this nail looking at objective data, and then you start looking at Can you get the fashion clothes and the operative time? The hernia volume makes a huge difference. The extra Donald volume makes a huge difference. But even breaking this down further, essentially all the negative connotations. Looking at wound complications, Readmission Re operation Recurrence Looking at the volume volume? Why absolutely the extra Donald volume? As far as complications go in readmission absolutely. The need for a per cutaneous drain. It's all about subcutaneous fat. Can you predict who's going to end up in the ICU? And we may talk about like how how tight you can close someone's admin and the people you might want to leave on a ventilator. And I'll just tell you, I never leave a single person on the ventilator, not ever. And I'll put my foot in the axle and pull the Adam together. Now people say, Well, the increase in tight A peak pressures of six make a difference. I mean, I don't know what to make of that. I mean, I put my foot in the accelerator will suit you. I'll do a running stitch, and then if I can't running stitch and things start to tear, I'll do interrupted futures. I'll hold the abdomen together, or I have Janet hold the atom together and I'm time. I interrupted futures. I come down because getting the fashion closed super important. Yeah, and I've kept one personal ventilator overnight, and I have no idea why I did it because I just made it up. But can the cats can actually help us predict this? So if you look at the cat, scan the risk for pulmonary insufficiency and going to the ICU body mass index makes a difference. Age makes a difference. Look at diabetes. I had no idea that 57% of the people who had where the highest risk had diabetes. It makes sense for asthma and COPD, but also where is the break point for looking at the CAT scan defect area? The larger the defect area. Look at this hernia volume, the highest risk folks to leaders outside the abdomen. And then if you look at what's really important here, if you look at the hernia abdominal volume of just over 50 When I start seeing just over 50 now, I'm like this patient may require an ICU stay Really higher, much higher risk, 50% outside, and a large defect, no matter what else they got. We talked about weight loss and I showed slides like this where people can lose weight and you can actually get them back together. This is a 15 centim defect, moderate loss of domain. Certainly gonna require a component separation I talked about. We showed this slide and this is her after after she had lost £35 and we completely got her back together again without a component separation, Of course. Then she want the plastic surgeon do a tummy tuck at the same time. Boom. You're welcome. And so but one of the things I would like I in my first lecture, I'm talking about comorbidities Get your comorbidities under control, etcetera, etcetera. And I used to tell folks all the time, go get your comorbidities under control and then come back and see me. The problem is, however, is hernias get larger over time, and this isn't like an umbilical hernia or a very small defect. But if you've got someone who's got a lap around the incision, a real laboratory incision, this is the same patient. 14 months later, you can see there's no change in weight, but you can see a dramatic increase in the defect size and then also beginning to get loss of domain I have now by not operating on this person pushing them off, they come back 14 months later. They're they're a different animal to repair. So if you follow this and follow these trends, If you look at this, if you look at the difference and I'm just gonna look at this left side of the draft, if you look at the change in defect area at 18 months, it's over 80 square cm. And then if you look at the change in the hernia volume at 18 months over 500 cubic cm. So now, instead of telling people to go get your life right, we need to follow up appointment so we'll actually have them come back to the office. And whether it's typically, it's somewhere between six and six and eight weeks, just so we can reassess what how we're doing. Because if you're not losing weight and you need to lose weight now, it's time to go to the dietician, the berry attrition or the bariatric surgeon. If you're still smoking, we got a double. We got a double down and try and get you to stop smoking. So follow up appointments. I don't make a living in clinic. And actually, I hate clinic. Let me just say I don't like clinic, but I have Janet there to do a lot of work and thank you very much. So, people, just to why did the hernias get bigger? The obliques. Just do what the obliques do They just pull the abdomen open the obliques, run side to side like Matt talked about. They just tear your admin open. So who's gonna need a component separation? And there's there is some data out there about looking at the, uh, judging by the cat scan whether someone will need a component separation. I know Will Will and Alfie actually published some information looking at the width of the rectus muscles and whether it impacted, what if someone we need a component separation or not, But you can't. Is there a better way to do this? And so this is some of the best work that we've done in a very long time, and I will again say we have done in a very long time. But looking at it like an artificial intelligence, can we look at CAT scans with artificial intelligence? Can medicine be made better with artificial intelligence and this we have just barely scratched the surface. And you think this is a new idea? This is from 1970, this paper in the New England Journal of Medicine. Mhm. And we're just getting around to it. But there is data with this. I mean, using artificial intelligence to review pathology slides. It's been demonstrated in breast cancer. It actually works pretty darn well. There is some head trauma predicting outcomes with head trauma using AI and you can we use deep learning and look at CAT scans. And then, instead of, like, kind of like this, You kind of go, You know, I think these people are at greater risk. Can we actually really make an impact with AI? And so but one of the problems is we don't know what the computer is looking at. I mean, is the computer looking at the subcutaneous volume? Here is a computer. Looking at the intra abdominal volume is a computer looking at the cuts of the chest. We have no idea because you load these, you load the slides in, you load the CT scans in, and what you end up doing is you give the computer the answer. So you pull out 350 cat scans 250 of them. You actually give the computer the answer? Patient needs a component. Separation or not, patients can develop a wound. Complication or not, patients gonna have pulmonary failure or not. And what the computer then does as it goes through all the cuts of the cat scans 250 CAT scans educating itself and looking at whether someone needs a component separation or not, you will do it over and over and over and over again Until it gets it correct 100% 100% of the time. And so we did component separation. How many times I went through all 250 cat scans 12,000 times until the computer trained itself. Who's gonna need a component separation or not? And then you load in 100 cat scans where the computer then is the test. And so we actually published this and Sharm el El Hajj. And, uh, Celia user did a great job. Just published this in JAMA surgery. Actually, uh, fish helped us with this, uh, as well. Again, we have 369 patients that we talked about and wasn't able to predict surgeon complexity. It actually was. It actually was able to predict the patients actually really quite nicely the patients who are going to need a component separation. And then we compared the computer to six experts in the world in component separation, and the computer actually did better than all of the surgeons and especially all the surgeons combined, developing wound complications and actually predicted wound complications beautifully from CAT scan. And, of course, our fellows were like We also try to predict pulmonary failure, But with pulmonary failure, our fellows were like really disappointed because it only only predicted just over 50% of the patients are going to develop pulmonary failure. Are you kidding me? If you can predict 50% of the patient's gonna develop pulmonary failure. that's fantastic. There's nothing like that that's ever been done in the world. And again, we can go back to this information. And almost 55% of the patients, they the computer, accurately predict where the patient is gonna develop pulmonary insufficiency or failure and go to the i. c. U. And they called it a failure. And I'm like, Are you kidding? That's fantastic. So in 20 minutes, this is about CAT scans and and the use of cat skin and a doll reconstruction and think it's super important. Uh, you know, I look at these. I review the cat scans of my patients on Sunday evening or sometime on Sunday morning for the week before review. The review, their whether who I'm going to operate on just to make sure everything's tidy. And then I review them the day of the operation. And I'm always Janet pulls them up at the time of the surgery. And when the patient's going to sleep, I'm reviewing the CAT scan that Janice pulled up while we're getting the patient ready. And I think it's a It's a super great way, uh, to have a road map to the operation. Thank you very much, guys. Mhm. Okay. Mhm. Yeah. What? Listen, I mean, so what we're actually now doing is we actually, our work. We just got, uh, RB approval to go through will and all these data. Uh, Jeremy's data Greenville hospital system. Uh, we're working to get I R b approval. We just We've got a legal contract with Ohio State. We're working to do it at University of Pennsylvania. As soon as we put we got to make sure it's not just a Charlotte phenomenon, and then we're gonna take a nap out of it, and then we just give it to you and just load. Your cats can just load your cat scan. But we just gotta get outside information to make sure it's not just a Charlotte phenomenon that I mean, probably. Well, I grew up in South Carolina with number 49 in public education for a reason probably. Yeah. No, Mississippi. I mean, anybody in here from Mississippi? No. Okay, Right breakdown. Thank you very much. Appreciate it. Take a break now. Mhm. Published December 15, 2021 Created by
