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applications are due March 1st. Again, applications are due March 1st. All specialty teams will get access to BTK resources, including microphones, software, help with editing, social media love, and so much more. dominate the day. Hello and welcome to another episode of Behind the Knife with the Hernia Team at Cleveland Clinic. I'm Sarah, here with Mike Rosen and Clayton Dietro.
Today we're reviewing our group's recently published randomized control trial, open retromuscular sugar baker versus keyhole mesh placement for peristoma hernia repair. To briefly summarize the trial, this was a single center parallel arm superiority trial that compared open peristomal hernia repairs with permanent synthetic mesh placed in either retromuscular sugar baker.
or retromuscular keyhole mesh configuration. And our primary outcome was peristomal hernia recurrence at two years. So can one of you please tell us what inspired you to address this question in a trial? Sure. Well, first of all, thank you for having us on to discuss this. This is a lot of work. This is five years, three years of enrolling patients and two years of follow-up. So certainly a lot of work went in this.
And we appreciate the opportunity to get to sit down and talk about it. So, you know, in surgery, when there's a new technique, I think the retromuscular sugar breaker technique is relatively new. When there's a new technique, I think there's always a lot of upfront excitement. And when you look at some early data, obviously there were some optimistic findings in terms of reducing recurrence rates.
And we had some of our own retrospective data that showed as much as a 20% reduction, 30 to 10%. And that's a huge signal. And if something is that significant from a research perspective, we get really excited because from, you know, in the terms of designing trials. You can start to do a trial in a relatively reasonable amount of time when there's that much of a difference. You can power a trial appropriately to find that difference in a randomized fashion.
We thought not only would it be important to the literature to show that there actually was that much of a benefit, but if there is that much of a difference, then it's also feasible as well. So I'll tag out a little bit to that. I think like almost all clinical trials that we've done here, our kind of impetus behind doing it is because we thought we figured out the answer and we were excited to prove.
that we knew what the best technique was. And I think that if you look at the trial design and look at kind of our historic data, everything in hernia, particularly with peristoma hernias, like Clayton said. There's initial excitement. That excitement spurred us on to look at this in a rigorous scientific way. And I'm sure as we'll get to, like most clinical trials, we proved ourselves wrong.
Can you please, before we move on to describe more of the trial, just briefly describe the difference between a sugar baker and a keyhole? Sure. So, you know, in a modern retromuscular... hernia ventral hernia repair there's three layers there's a posterior sheath repaired neon layer that gets closed we lay a piece of mesh on top and then we close the muscle on top of that
And so at the end of the operation, you have to bring a piece of bowel through the abdominal wall. You have to bring it through all three layers. A keyhole technique makes the hole in all three layers line up in a straight line. And in a retromuscular sugar baker technique, the bowel comes through the peritoneum, drapes on top of the mesh, and goes through the muscle, and it's in kind of offset holes. So the holes are...
kind of offset from one another and it creates a bowel effect. So typically a posterior sheath hole is more lateral. anterior sheath yes typically it doesn't have to necessarily be lateral it can be any direction that's offset from where the anterior hole in the muscle is okay
We had previously published the short-term safety outcomes in surgery, and those are 90-day outcomes. That actually showed that there was pretty significant wound morbidity in both groups, but there was no significant difference. We had about a 16% SSOPI. surgical site occurrence requiring some kind of procedural intervention rate. But then again, there was no differences between the sugar baker and keyhole arm.
We did have a few re-operations in the Sugarbaker arm that we felt were related to the technical complications. But at that point, we were still waiting to see the data on the long-term peristomal recurrence, which is what was published in JAMA Surgery. Yeah, I mean, I think, first of all, you know, anytime you take on, I would say, all retromuscular surgery, the technical challenges of retromuscular surgery are significant, and we've certainly learned.
over the past decade as it's become more and more accepted that these are challenging operations and when you add a stoma and some of the things that clayton mentioned Not just the dissection of that, but also the architecture and the arranging of everything under tension without making it too tight, without kicking it too far. These are very, very challenging operations, and I think that's probably one of the biggest take-home messages.
from this trial is, you know, I would say we're a fairly high volume center. You know, 150 patients randomized for peristomals, I think might be the biggest trial ever done for peristomals. And so even in our hands, folks who do this stuff. fairly frequently, the morbidity is real. And so I think just taking a step back and realizing and kind of talking with patients about
You know, these different approaches, you know, the sugar baker, there is an upfront price to pay of getting this all angulated. And I think one of the keys to a sugar baker is just realizing, as Clayton described it, that this is a... kind of a balancing act between enough offsetting without excessive kinking. And I think Clayton and I have both done a lot of these, and I think we would both agree.
That's much more art than it is science, and it's very difficult to describe to folks kind of where that magic line is. And in this trial, at times, we probably pushed it too far. And at times, maybe we didn't push it far enough. And so I think that's the kind of subtle technical aspects of these operations that everybody needs to kind of take it with a grain of salt.
And this is one of the things about trials being done in high-volume centers. A lot of times you take technique off the table, but I think this highlights that even in a high-volume center, technique was still challenging, and there were technical complications. These are difficult operations.
Yeah, these were humbling cases. I think just looking at the wound morbidity by itself, you know, the 16% wound morbidity, that is just a reflection of these being really challenging, you know, contaminated cases of bomb in the wall reconstructions.
And then I think, like you alluded to, the recurrence component of this is so important because if the sugar baker technique really does reduce the recurrence rates by that much, then... it might be worth adding a little extra tension trying to get the holes a little more offset and you might you might accept some of those potential you know rare mesh related complications at the stoma site if you were giving
a huge benefit on the back end in terms of reducing recurrence rates. And so the value of the operation was really going to require both the peristomal mesh complications and the recurrence data so that you can kind of sit down at the end and... you know, make an educated decision about what's best. Okay. Let's get a little bit more into how we designed the trial. So as we mentioned, this was a single center trial at our high volume center. We had blinded patients and assessors.
In terms of inclusion criteria, patients had to have a permanent stoma or they had to be undergoing a permanent stoma creation in the setting of an existing hernia. And they had to be a candidate for an open retromuscular peristoma repair. We excluded patients who had two stomas preoperatively, or if intraoperatively, they were deemed to have insufficient bowel length to be randomized, or if mesh placement was not saved at the time of surgery.
So randomization occurred intraoperatively once the patient was deemed to have adequate bowel length for either technique. And we powered this to detect a 20% absolute reduction in peristomal hernia recurrence at two years. So can you talk to us a little bit about how we defined recurrence? Because I think that might be confusing. So this was really challenging because there actually is no standardized way.
that we can all agree upon in terms of how do you define a peristomal hernia recurrence. And so certainly on CT scans, sometimes it might, even though the patient feels a bulge,
You can look at the CT scan and it doesn't necessarily look like there's a recurrence. And so we had to kind of decide amongst ourselves what we were going to call a recurrence. And what we decided upon was since the most clinically significant recurrences would be those that had a separate loop of bowel that was going through the aperture.
that would potentially be able to cause an obstruction, we decided that that would be what we would call a recurrence. And there's actually a classification system that we cite in the paper. And that had previously been defined as the Mario Matthias classification system. And I believe it was a class three or class four. Yeah. Yeah. So we just we landed on that as what we would call a recurrence.
So I'll add a couple things, maybe not quite answering the question that you asked, but you brought it up in kind of how we powered the study and how we came up, because I think that that has to be brought into... That is an often underrated, incredibly important aspect of any clinical trial is kind of where you set the goalposts and the differences and how many patients you need to do that.
you know, always comes into, are you underpowered? Did you really not find a difference, but there might have been a difference? And so it's important to look at that in the space of recurrence. And you had mentioned, you know, we... powered this study off of a prior study that we had done looking at biologic and synthetic mesh and we had done a post hoc analysis of sugar baker versus keyhole and it was actually a two-year follow-up.
And it was 30% in the keyhole and 10% in the sugar baker. And, you know, at the time, and those were anatomic recurrences just like here, at the time, you know, there was a lot of excitement. And I think it's important to realize when we talk about, well, are we underpowered? Nobody really questioned that difference. And I think clinically in the world today, that's what most people think a sugar baker probably does. There's not a lot of published data out there about sugar bakers.
particularly retromuscular sugar breakers. But I think that using that data to power this, we expect it to find a 20% difference. And I think most surgeons who are doing sugar breakers think that there is a... significant reduction in recurrence rate. And so I stand by that, but also acknowledge that we might have been underpowered to notice a small difference. But I always kind of revert back to...
You know, if you're not doing 75 peristomals in your life, if it takes us a thousand patients to find a difference, is that a clinically relevant difference? Clayton, what do you think about that? So I thought about this a lot because clearly...
if nothing else the retromuscular sugar baker appears to at least delay the recurrence of the first year and then by the second year they're much closer certainly not what we powered it to be but still a difference and so let's imagine a world where we had you know seven or eight hundred patients and we randomized them and there were still the same difference but now we have a different p-value.
You still are left to reconcile, okay, is it worth pursuing that technique? And at the end of the day, let's say that there's a 7% difference at two years, which is what we found. And let's say that even in a larger set of patients, that's the same difference, only now you have a significant p-value.
I think there's kind of something here for everybody. I think if you have a patient with favorable anatomy and you're a skilled surgeon who's done a lot of these, of course you're going to give the patient the delayed recurrence.
Or the chance, you know, a lower chance of getting a recurrence of two years. If you're someone whose anatomy is not favorable, you've not done a bunch of these, then you can rest assured that it's really not that much of a difference. That you're not really withholding some great thing and you're not going to maybe...
try to overdo it and set the patient up for a for a mesh complication at the stoma site just because you tried to force it so i really think no matter kind of which end of the spectrum you're on in terms of being you know a four against this operation there's kind of something there for everybody well let me ask stuff clay to follow up on that so if so although we didn't study this but you have a lot of experience we've looked a lot of ct scans together and so
What do you think the difference is in the mechanism of recurrence that we've learned from this trial that people could take from and try and apply the best approach that we understand? for the right hernia. And I want to make one quick caveat before you answer this, because we didn't mention this, but it is important to discuss all these patients almost exclusively had large midline hernias as well. And just I want to put out there before you answer that.
We do think that there is a space for minimally invasive surgery for stomas. It's not in these patients because they have large midline defects. So the isolated. peristomal defect after a lap APR or robotic APR is not addressed in here and the kind of dilemma between robotic or lap IPOM, sugar baker versus keel, we have not addressed. But what do you think about the difference?
just personally from looking at my my per like sugar bakers that recur because sometimes you think by sugar baker and there's all that overlap and in the perfect sugar baker you've got maybe 10 or 15 centimeters of offset how could that possibly recur and the ones that at least that i've noticed are the ones where you're taking the ilium and you're trying to put it on the left side or maybe the transverse colon and you're trying to put the stoma on the left side
just because that's where the patient wants it or that's the most favorable place to put it. And when the mesentery seems to pull the posterior part away, it seems like whatever offset you had, when the tension is on the posterior sheath, pulling that... that what you think is a lateral aperture.
back to the middle, then the holes just start to line up again, just like a keyhole. That's the ones that I've seen. And what about a keyhole? Because it's interesting, when you look at the keyhole, it came early, and then it kind of stopped. Yeah, so the keyholes probably...
That has a lot to do with how tight you make the aperture. And so that really, since those seem like if they're going to recur, they're going to recur right away. And so why would that be? It's probably more technical in terms of you just didn't make the aperture tight enough.
How do you make it? Yeah, how do you know? Who knows? I mean, like, that's unknowable. I really, you know, I don't know. And sometimes I will, you know, sometimes you have to make it large enough to get a bulky mesentery through it. But then wherever it sits might be a little thinner. And so I've been even sometimes I'll throw a stitch just to make it a little more snug after I've done. Yeah. So I think that.
there is like a hammock effect for sugar bakers, right? And then there is also a fear of keeping mesh too close to the bowel. And there's one thing we didn't mention in this trial. I think it's in the paper. I can't remember the exact numbers. Maybe you guys do. But we had pretty much abandoned transfascial fixation sutures. And I think that at least our feeling on this is that by abandoning the transfascial sutures, we abandoned kind of the guillotine effect.
And to my knowledge, we didn't have any erosions with the keyholes, did we? But we had had that in the past. And so at least we think today, avoiding any trans-fast fixation allows the mess to lay. And I think the keyhole...
One of the tricks is to, I don't know how to say it either, but other than to make it uncomfortably tight. If it's an ilial conduit, just urine has to get through it. If it's, you know, a colostomy, I like it to lie up on there. And I agree with Clayton, I'll bring it back pretty close.
And I think for a sugar baker, this is one of the things you have to be able to judge. I think there are times you can get incredible lateral coverage, but when you can't, it might be an inferior operation. We'll go back and pull out all these things and look at all this stuff.
But I think that's our cut of $30,000 for a view of it too. Hey, Behind the Knife listeners, it's Kevin here. Do you dread doing your notes at the end of clinic? Do you feel like you can never get ahead of charting? If you are shaking your head yes, keep listening. Freed AI is a medical scribe on a mission to free clinicians everywhere. Freed AI listens, transcribes, and writes medical documentation for you. Written in your style and ready the moment the visit is over.
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Freed is used by over 6,000 clinicians from every specialty. Give Freed AI a shot to help you with your clinic. BTK listeners get 50% off their first month with code BTK50. That's BTK50. Now back to the show. We kind of alluded to a lot of the results, but just to go over it for completion's sake, we had 150 patients enrolled in the trial, 75 in each arm. We got about 91% follow-up at two years, which was excellent. Baseline characteristics were similar between the patients and most operative.
characteristics were also similar, except for a few things that were technically different between sugar baker and keyhole. So I think that one of the biggest criticisms of the trial is that in the keyhole group, and I'm going to try to go through this slowly. the keyhole group that the stomas were more likely to be recited and the reason is is that most of us doing these here if we get randomized to a keyhole technique
we would prefer to bring the stoma down and bring it through a cruciate incision rather than slit the mesh and have to sew it back up around it. Now what that means is if you take the stoma down, the stoma is more likely to be recited in a new location and so when you do that you're now you know creating prophylactic reinforcement around that stoma rather than compare that to a sugar baker where one of the biggest
advantages of that technique and the the supporters of it are that you don't have to take the stoma down because you don't have to worry about bringing the bow through a piece through a hole in the mesh and so you you can leave the stoma where it is and that you know is a different philosophical assessment of that stoma site because the stoma peristomal hernia was there you're fixing it without moving it and you're reinforcing it as opposed to one you take down and put in a new spide
And so that difference in prophylactic reinforcement versus in fixing the stoma site was inherent to which arm you got randomized to. Now, obviously, that was going to confound.
the results and so we knew that that was going to happen and we you know planned ahead of time to look if reciting the stove mattered and that did not seem to but just recognize that that you know If you think that you're putting the sugar baker at a disadvantage by allowing the key old folks to get recited, just recognize that proponents of the retromuscular sugar baker technique often cite
not needing to move the stoma as an advantage so it can't be both it has to be either an advantage or a disadvantage because if you think that the sugar baker being able to keep it where it is is a disadvantage well then you should be taking it down and moving it so
And I would just add, I think this is one of the things that we've done a lot of this work and our group has around trying to design randomized controlled trials with the background noise of complex abdominal wall reconstruction. And I think that. As Clayton mentioned, there's a trade-off to this and these really should be considered pragmatic trials in that we cannot force surgeons to do certain technical things.
because the situation does not allow for it or suggest it's the appropriate thing to do. And so again, I think to me, at the end of the day, when you look at it, there is a piece of bile going through a mesh. either straight or with a gradual S configuration. And ultimately, that's what we're after. And I think that the kind of excitement around the retromuscular sugar baker...
has been such that it was the fix for peristomalism. And just to be clear, that's what we thought we were going to see. We didn't think this was going to be even close. to not different and at the end of the day by waiting it out getting long enough follow-up lo and behold like this is a hard operation and we haven't found the magic bully yet.
So we also know that parasillinal recurrence at one year was significantly different. It was lower in the sugar baker arm at about 8% versus 21% in the keyhole arm. which is kind of interesting because the idea of the prophylactic mesh is that you should slow, you should delay recurrences. It doesn't really seem to have had that effect on this population. But by two years, there was no difference between the sugar vaca and the keel arm.
a 17% recurrence for sugar baker versus 24 in the keyhole arm. And that difference persisted even after we did adjusted analysis for all of those features that we thought would affect recurrence rate. So what do you do with this information now clinically? So, yeah, I think it's like I said before, I think that. If you have the skill set and you have favorable anatomy, I think there's still a benefit to trying to pursue a retromuscular sugar baker. That's kind of my go-to.
However, now I have a little bit of peace of mind that if the anatomy is not favorable and if I feel like I'm forcing it, I'm not going to put myself in a situation where I'm going to put a lot of tension on the bowel. and potentially cause a mesh erosion just because i'm trying to you know do a retromuscular sugar wringer it's not worth it and i can have the peace of mind that i'm not giving the patient too much of an inferior operation
So I would say for me, I use it a couple of ways. It started within my patient kind of discussion when folks come in with peristomal hernias. And I say, you know, listen, we know roughly about one in five are going to come back. That's substantially higher. with radiographic recurrence than our typical hernia repair. So my first discussion is, you know, unless you're really symptomatic, meaning your bag's not fitting, you're having obstruction, you're having pain, leakage, whatever.
that i i try and discourage people from having this done and i kind of look at it i look at this like i do most hernias now it's a little bit like orthopedic surgery right like orthopedic surgeons try and hold off you're getting your hips and knees done until as long as possible inevitably you're probably going to need it but the operations don't last forever they have a high recurrence rate it's a high mechanical load and you add a stoma it's even worse so i think number one
I think 20% is a pretty good recurrence rate, to be honest, but it's still one in five and it's higher than a normal hernia. So I have that conversation with the patients right up front. And then number two, and I really, you know, I want to agree with what Clayton said too, is that it really gives me a little bit more confidence to do a keyhole, but keep the hole tight.
And again, we haven't measured the hole and not all that, but I think that what you see with the keyhole and the pattern of recurrence with the keyholes, I think it is that the hole was too big.
early recurrences if the hole's not too big and it scars in the recurrence rate really levels off so again i will have a low threshold to do a keyhole but i would also agree with clayton kind of my preference is if the bowel is really able to lateralize and you can judge that that i do like a retromuscular sugar baker what do you think is the next step to try and address the problem of parasomal hernia recurrence well honestly
So if you look at this from the perspective, okay, we thought we had the magic bullet. We don't. It does seem like a significant proportion of these come back no matter what. It does make you kind of circle back and go, okay, I know I'm going to be fixing these again. moat a lot of the time. And coming from a place that, I mean, we use almost exclusively synthetic mesh here. And for these peristones, it's medium-weight polypropylene. And I haven't put a piece of biological or pyosynthetic in.
since uh mike finished his biologic synthetic trial years ago but if you know it does make you kind of circle back and go okay if i know that there's a lot of these that aren't going to be coming back if i have to be doing redo retromuscular peristomal hernia surgery Are these the patients who should be getting, you know, biological biosynthetic mash? And I'm not, I'm not a, you know, I don't be paid by any of these companies, but I do think it's at least worth a consideration.
I don't know, Mike. Yeah, I mean, I think, look, there's a bunch of unanswered questions, right? And I mean, the questions come down to what can we do with the patients, what can we do with the mesh, and what can we do with the technique, right? That's where the answer to the majority of our problems are. I think from a patient perspective, there's not much you can do. I mean, they have a stoma from the mesh. I agree with Clayton. There's a lot of unanswered questions.
support Clayton's comment about this, the study that we powered this off of the biologic versus synthetic, there was no difference in the peristomal recurrence rate. The only issue, which is the challenge, is a lot of these people had midline hernias, and there was a difference in the midline hernia, meaning that the synthetic was better in the midline.
but they were equally as bad at the stoma site. And so I think all of this, ways in making those decisions, I kind of more rely on or think about there might be more technical modifications. never-ending effort to do less peristomal and get my partner, Dr. Clayton Pichot, to do them. I want to let you guys know about what I think is maybe the best modification. We call it a key baker.
But I also refer to it as a Petro parasomal hernia repair. And that basically, I think if you think about what Clayton said, it takes the best of both worlds, right? Is if you think about the hammock effect. a sugar baker, meaning that you kind of push the mesh off to the side and there's almost like a turtleneck budging up around the stoma.
We've done and we're actually looking at the data right now. I think we've done about 75 and we'll wait till two year follow up now that we know this. But this operation is essentially a sugar baker. But then you perform. So it's a sugar baker at the hole through the. rectus muscle and then it is a keyhole as the stoma goes through the posterior sheet so it combines so now you've wrapped the mesh out laterally and you can either do it as a cruciate
Or you can do it as a lateral slit and wrap the tails around. And again, to me what that does is it gets a mess out laterally, might decrease the hammock effect. But again, to be completely honest, we need two-year radiographic follow-up in 75 patients and see whether this is the answer. I'm sure it won't be the whole answer.
But I think that, you know, my feeling is at least my recurrences were kind of not getting it lateral enough and just the inherent weakness of a sugar baker that you just don't have mesh. lateral to the stalemate. So I think this Key Baker concept is exciting and new, and we'll have to track that and see what happens. Again, we'll never find the answer, but hopefully we'll keep getting better and better. Please don't ever call it.
a pizza and fake wait 10 years and then all and then then we could do when we all find out it's a bad idea yeah my luck it'll cause like that'll be yeah one other thing that i kind of just wanted to talk about is We've already talked about that we had a lot of midline hernias and they were very complex. Our average defect was 15 to 16 centimeters between the groups. So I think we didn't really address what to do with an isolated peristomal.
because maybe it shouldn't be that we jump to a retromuscular surgery for those isolated peristomals. Maybe a minimally invasive is better to keep that playing for the future. Yes, I feel pretty strongly about this. I think we've gone through the phase of the, you know, everyone wants their video of an ETEP, you know, unilateral tar doing a sugar baker.
and and that's great it's a cool operation but i just i think when you start thinking even when i do these open if i can spare the tar plane on one side because i know in the back of my mind i'm thinking You know, 20% of the time I'm going to be back here in the future. I got, you know, 25 years of career left. I have to plan for the future. So I do think, you know, violating these planes in a minimally invasive fashion.
should be done thoughtfully. And I think there's nothing wrong. One of my favorite robotic operations is a robotic intraperineal mesh. I think that's like one of the best uses of the robot because it kind of lets you set the tension of the mesh. to get the the holes offset and so i think intraperineal ipom sugar baker is a great operation and i would definitely advocate for that over some of the you know some of the retromuscular techniques
Yeah, I would just tag on that. I think importantly, we kind of touched on this before, but just to reiterate it, is our data does not address that question. We don't know that, I think. that should be put to a multi-center randomized control trial because i think it's an important question of keyhole versus sugar baker i agree minimally invasive retromuscular peristoma hernias
It's not worth it. You still, you know, if everybody just steps back, at least the purported advantage of minimally invasive retromuscular surgery is to keep the bowel off the mesh. But in a peristomal hernia, there must be bowel on the mesh if you're doing a sugar breaker. So the operation will not afford that. So to go in there and violate that plane, make it much, much more challenging.
Really makes no sense. And I agree with Clayton. I think that's the sweet spot of the robot. I think you can so much more elegantly close the defect. It's hard to do that with the Card Thompson. And while you can so at lap, it's much, much harder. And I think... being able to position the mesh just the way you want it. And the other thing is, the majority of these cases are either a robotic or lap APR or a robotic total colectomy with an endolyostomy.
Both of those set up nicely for a sugar breaker to the right or sugar breaker to the left. And doing it minimally invasively makes sense. For me, if they have a midline hernia, I think it's too much with the mesh. It's not wrong to do it minimally, basically, but it's a little bit much. So the midline hernia to be is going to take us to open. And the isolated ones, I think MIS is a great approach to the right patient. Yeah, I mean, my final comment about this is I think, like, you know, look.
When all trials come out, there's an initial like, oh my God, how can this not prove my bias? And I think that we would be remiss if we all didn't say that we have those feelings before we write these papers. We wanted to have a winner. We take care of these patients every day. We want something to win. We want it to be an easy answer.
But the one thing I think we've all learned from all these trials is the answer is often not easy. And it's confusing, it's complicated, and there's bias, and there's confounders. But I think that to me, the biggest take-home point for this is... Everybody in the abdominal wall reconstruction community take a deep breath and realize that peristomal hernia repairs are challenging. They're complex. The results are not perfect.
And sometimes doing the operation that you feel most comfortable with is perfectly appropriate for the patient. You don't need to push it into more advanced things that can potentially get you in trouble and irreversible things, particularly when they fail.
Yeah, I think the only other thing that I would add is follow your own outcomes too. If you're getting really good outcomes with keyholes, why would you change? And if you feel like you're getting... you know even better results than we are with your sugar bakers then again you know that that supports whatever you're doing so i think that you know there there might be variability surgeon surgeon there's so many subtle
technical things in these operations that we that we talked about the tightness of the keyhole aperture how good you are offsetting the holes in the anterior and the posterior sheath there's gonna be some variability surgeon to surgeon and so
Follow your own outcomes and, you know, whatever you are doing that works, keep doing that. Thank you to Dr. Petro and to Dr. Rosen for sitting down with me and talking through this trial. And from all of us, the hernia team at Cleveland Clinic, dominate the day. Be sure to check out our website at www.behindthenife.org. Download our free app available for Apple iOS and Android. Simply search for Behind the Knife in the App Store or Google Play to download the app.
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