Should Rural Surgeons Perform Thyroid Surgery Without Nerve Monitoring?
Dr. Ronald Weigel returns for Part 2 of his conversation with host Dr. Randy Lehman on The Rural American Surgeon. The discussion continues with a practical look at what cancer care rural hospitals can safely keep local, when patients should be referred, and how smaller hospitals can build sustainable surgical programs even without 24/7 general surgery coverage. Dr. Weigel explains that common cancers such as breast cancer, colon cancer, melanoma, and some prostate cancers may be appropriate for rural treatment depending on the surgeon’s experience and the hospital’s capabilities.
The conversation then moves into patient-centered breast cancer care, including mastectomy, reconstruction, rural patient preferences, and why treatment decisions should reflect what individual patients actually want rather than assuming every community has the same priorities. Dr. Weigel also discusses how Commission on Cancer accreditation, tumor boards, rural-specific quality metrics, and participation in the National Cancer Database can help improve care and generate better data about cancer treatment in rural communities.
Later, Dr. Lehman and Dr. Weigel get into the nuts and bolts of rural surgery, including recurrent breast abscesses, lumpectomy incision placement, margin techniques, thyroid and parathyroid surgery, and operative exposure. The episode culminates in a direct discussion about whether rural surgeons should perform thyroid surgery without nerve monitoring. Dr. Weigel shares why he has not routinely used nerve monitoring in his own thyroid practice, while emphasizing careful identification of the recurrent laryngeal nerve, surgeon judgment, appropriate patient selection, and knowing which procedures belong in each individual rural practice.
Key Takeaways
00:00 Welcome Back to Part 2
00:17 Cancer Care Without 24/7 Call
02:02 What Cancer Should Stay Local?
03:22 Investing in Rural Surgical Capability
04:14 Breast Cancer and Reconstruction
06:09 Understanding Rural Patient Preferences
10:14 Accreditation and Surgical Standards
10:57 Tumor Boards and Continuing Education
11:26 Building Rural Cancer Quality Metrics
13:01 Why Rural Cancer Data Matters
14:19 ACS Rural Cancer Resources
15:45 Building Trust With Rural Patients
21:13 Rural Surgical Case Decisions
22:24 Managing Recurrent Breast Abscess
25:09 Lumpectomy Incision Techniques
29:03 Using Shave Margins
32:42 Thyroid and Parathyroid Surgery Pearls
35:09 Bringing Endocrine Surgery Back Locally
36:29 Is Nerve Monitoring Necessary?
38:28 Parathyroid Surgery Without Intraoperative PTH
41:25 Deciding What Stays Local
41:53 Final Advice for Rural Surgeons
Resources Mentioned
American College of Surgeons
https://www.facs.org/ ACS
Commission on Cancer
https://www.facs.org/quality-programs/cancer-programs/commission-on-cancer/ ACS
National Cancer Database
https://www.facs.org/quality-programs/cancer-programs/national-cancer-database/ ACS
University of Iowa
https://uiowa.edu/ uiowa.edu
American Board of Surgery
https://www.absurgery.org/
ACS Rural Cancer Programs
https://www.facs.org/quality-programs/cancer-programs/
Episode Transcript
Dr. Randy Lehman (00:00):
Welcome back to the Rural American Surgeon. This is part two of my conversation with Dr. Ron Weigel from the American College of Surgeons and the Commission on Cancer. Let's jump back into the conversation. And so like for the three hospitals in Indiana I'm at, they have all done away with 24/7 call. So what I've done at one hospital, which is where I do my bigger cases, which to me are essentially now hiatal hernias and colon resections, those are like my bigger cases, is they've put together like a 24-hour call team for me, and that's what I've got. Now, I possibly could call, but nobody's obligated to come back beyond that point.
Dr. Ronald Weigel (00:44):
Yeah.
Dr. Randy Lehman (00:45):
If i had a problem and i've been getting by with it um it's not as good as having 24 7 you know but what about i mean have you encountered hospitals that are sort of to that level where they have a general surgeon like two days a week and they don't have overnight call capabilities would a hospital like that still be able to do this type of accreditation program?
Dr. Ronald Weigel (01:12):
Yeah, I think they would. I think, you know, most cancer care, almost all cancer care is elective. I mean, yes, these individuals get emergencies, no doubt about it, but cancer care is basically elective care. And so, yeah, I think that that's certainly possible without having 24-7 coverage. And, you know, what you're describing is an evolution in how we take care of patients. Providing that 24-7 coverage is, as I said, very difficult when you don't have enough of a group of call schedule. I know we get a lot of transfers at nights and weekends at the University of Iowa from the surrounding area because you're right. I mean, they just don't have 24-7 coverage.
Dr. Randy Lehman (02:01):
What cancers should we be trying to keep local? in these environments? And then where, on the other hand, should the rural surgeon recognize that the better care is referral?
Dr. Ronald Weigel (02:12):
Well, again, it depends upon what people feel comfortable As you described, a general surgeon's practice can be extremely heterogeneous, and they can cover a lot of things to keep themselves busy. Within the cancer realm, I would think that most breast cancer can be treated in these rural hospitals. Colon cancer can be treated at these rural hospitals. Melanoma can be treated at these rural hospitals. If you have a urologist that can come, there's... you know, being able to treat prostate cancer is certainly very reasonable at these local rural hospitals. And then the question is what the capabilities are of that hospital.
Dr. Ronald Weigel (03:03):
A lot of these hospitals will put in place a robot and they'll offer robotic surgery and the robot gets used for doing hernia repairs, you probably use a robot for your hiatal hernia operation.
Dr. Randy Lehman (03:17):
I would if I had one.
Dr. Ronald Weigel (03:18):
Yeah. Exactly. But again, it's getting the administration at the hospital on board to make the investment. A lot of CEOs at hospitals, the way they think is they increase their bottom line by cutting services and cutting costs. They're in the cost-cutting mode. I think most surgeons think about improving the bottom line of the hospital by doing more and expanding. And it's a completely different mindset.
Dr. Randy Lehman (03:46):
But I think that- You might have just exposed some of my main frustrations in life. Wow. Right.
Dr. Ronald Weigel (03:52):
We've lived it. I've lived it. And I think that- recognizing that accreditation, investing, robotic surgery that can be done safely at a rural hospital can give you expanded capabilities and actually improve your bottom line while it's improving the care that is received by those patients.
Dr. Randy Lehman (04:14):
How do you handle breast recon?
Dr. Ronald Weigel (04:16):
Yeah. So that's much more difficult. I think that when I came to here to the University of Iowa, we didn't have any plastic surgeons doing any sort of plastic reconstructive for breast surgery. And I was doing mastectomies on young women without the ability to do reconstruction and having to have them have delayed reconstruction, which was really terrible.
Dr. Randy Lehman (04:36):
So one of- So how'd you leave the skin on those patients?
Dr. Ronald Weigel (04:39):
I just did a regular mastectomy.
Dr. Randy Lehman (04:41):
Simple mastectomy, but they were flat?
Dr. Ronald Weigel (04:43):
They were flat.
Dr. Randy Lehman (04:44):
Because I've heard of people doing this like in conjunction in rural places, in conjunction with a plastic surgeon that they might have seen ahead of time, but they still got their cancer operation at the rural place and then closing them over a drain, but leaving the skin. So it's kind of saggy, you know, and then they go and do their.
Dr. Ronald Weigel (05:03):
Recon later i don't know carry on it contracts down but i think that if you got a plastic surgeon that you're coordinating that with and getting a plan together and saying okay how do you want me to do this i think would be the right way to do that but you're right reconstruction is much more difficult. In reality, a lot of my patients that came from rural areas were not interested in reconstruction. In fact, I remember one patient that I did a mastectomy on her and closed it all up. She was so pleased and then didn't, you know. had another mammogram. Oh, maybe there's some calcs. Didn't want to deal with it and just wanted a complete, you know, a prophylactic contralateral mastectomy.
Dr. Ronald Weigel (05:52):
And so, you know, I did that for her and she was just very pleased with it. Didn't want to have to deal with reconstruction. Didn't want to have to deal with more mammograms. and then could largely be followed by physical exam and was happy with that.
Dr. Randy Lehman (06:08):
100%. So let's riff on this for just a second. There are breast papers that describe higher rate of mastectomy in rural places and malign the rural surgeons. And what you're saying is you are in a referral place seeing that the patients that came from a rural environment actually wanted something different than the urban patients wanted which has been 100 my experience with patients and with my own family my mom had breast cancer and it was would have been a candidate for breast conserving treatment but she elected not just mastectomy on one side, but bilateral, simple mastectomy, no recon, was very happy with the result.
Dr. Randy Lehman (06:58):
And I've had patients, even young patients, I had a patient in her 20s that came in essentially demanding that. And she said, I don't have time to do MRIs. I don't want to do, you know, alternating six months MRI and ultrasound. And I just I don't need them. I don't want them. I don't want recon. I try to like push her to like talk to, you know, a plastic surgeon, all these things. Didn't want it. That is the reality is the people that are in my communities. There are some people that match up with the mindset of the breast conserving group in the city or whatever. But in general, the follow up is more difficult.
Dr. Randy Lehman (07:38):
And the people are quite practical, like much more practical, and they're different. I mean, if you look at other things, like like how they live their life, you know, it's a very different person that chooses to live. And we're not here because we have to live here in this. town of 6,000 people. We're here because we want to live here. And we're a different kind of person. You look at how people vote and how they live their daily lives and the activities that they do. They're all very different. And so this is like a little, I want to hear your perspective on this because of all people, you're like the perfect person to get an opinion.
Dr. Ronald Weigel (08:11):
Yeah, my experience is the same as yours, that there are a lot of women in rural communities who are not interested in reconstruction. They want a simple mastectomy or a simple mastectomy and a sentinel node biopsy, and that's it. And sometimes even will refuse. you know, chemotherapy. And they just want their simple mastectomy and it shortens the amount of time that they have to spend in convalescence. And they're perfectly happy with that. And so that's always been a key of my practice is listening to the patient and treating the patient from where they're coming from. and not assuming that every patient is going to want exactly the same thing. I've dealt with patients on both ends of the spectrum, right?
Dr. Ronald Weigel (09:03):
I've had women, like we're just talking about, I want bilateral, simple mastectomy, no reconstruction. And I'll do that. And I've had patients on the other end of the spectrum, literally, who have said, if I had a mastectomy, I would rather die. then have a mastectomy. I do not want a mastectomy. And there I am trying to do an extended lumpectomy with oncoplastic reconstruction to avoid a mastectomy in a patient who clearly needed that. And so you do your best to give patients what it is they're looking for and what And you have to come at it from listening to what it is they want and what they're saying.
Dr. Ronald Weigel (09:47):
And, you know, there's no place to what you're saying, maligning a surgeon for doing something that the patient wants. And it's silly not to think that people want something different. And I've done plenty of bilateral simple mastectomy on women, and they're perfectly happy. And particularly for larger breasted women, they don't want the asymmetry of one large breast on one side and, you know, flat on the other side.
Dr. Randy Lehman (10:14):
What about the accreditation piece to that? Does that play in like what decision for the actual operation or is it more like margins and nodes and whether they were offered sentinel node, et cetera?
Dr. Ronald Weigel (10:29):
Yeah, yeah. It's not, no, there's no mandate that you have to do breast conservation. It's just, you know, we're expecting the standard of care. And that standard of care obviously is tailored to patient preference and the patients in that community.
Dr. Randy Lehman (10:43):
And as the standard changes over time, Are there easy, quick hits for, you know, the rural surgeon that continues to practice in that same place for decades that they can use from this program?
Dr. Ronald Weigel (10:57):
Yeah, I think part of CoC accreditation is that. we also offer educational opportunities for individuals. And I think tumor boards are probably the best place to receive that day-to-day education because as new discoveries are made, we're publishing things all the time that are advancing care. One of the things that we're interested in doing, so with the current rollout, very first initial rollout of this Rural Commission on Cancer Accreditation by the American College of Surgeons, we have adopted the identical quality metrics. But we also recognize that it's probably required to have quality metrics that are more aligned with rural hospitals and rural communities. And for example, there's been a big push to de-escalate sentinel node biopsy.
Dr. Ronald Weigel (12:01):
And so there may be... quality metrics, which have been dropped by the CoC because 90% of places were already doing it, but they may be appropriate for rural areas where people may be still doing sentinel node biopsies on women over 70 who have ER/PR-positive cancer and are clinically node negative. And so we're working to... develop quality metrics that we believe are more appropriate for rural hospitals. In order to do that, that's why becoming accredited is so critical, because we don't have the data we need for rural hospitals. That's been part of the challenges to non-accredited hospitals, but we don't have the same granular data because those hospitals aren't submitting data to the NCDB.
Dr. Ronald Weigel (13:01):
So part of the push of having more rural hospitals engaged with the American College of Surgeons Commission on Cancer is that their data will here's how it's different. Here's how the quality might be different in rural communities versus not, versus urban communities, and then help develop evidence-based standards that are more appropriate for rural hospitals. But we need the data. And that's part of the advantage of having CoC accreditation is then the data gets put into our registry.
Dr. Randy Lehman (13:41):
That's great. I'm going to put all the links that you and your assistant send me into the show notes. And we'll have links for basically, if you're a general surgeon at a rural hospital, you want your hospital to pursue this, what you need to do, where you need to go on Monday morning to start moving things forward. I have one anecdotal story that I... want to talk about. But before I do that, is there anything else about the program that we didn't say that needs to be said?
Dr. Ronald Weigel (14:12):
Well, I think this has been good to get the word out. I appreciate, Randy, you taking the time to talk with me today. um there is a website that people can look for additional resources which i hope is included in your list which is facs.org/ruralcancer and it gives a lot of information and we'll make sure that you have that on your list of websites that people can go to to get additional information and We're here, we're available. The American College of Surgeons has a major push to improve rural care for patients, not just with cancer, but with trauma, with emergent general surgery, with all of these other areas.
Dr. Ronald Weigel (14:57):
And I'm very pleased that we have decided to focus on this with the help of many individuals from the Board of Regents. Timmerman and others who are in rural areas who are very interested in making sure that we advance rural care because it's a key area of disparities in care and access to care that I think the American College of Surgeons can really make a difference.
Dr. Randy Lehman (15:21):
No, thank you. This has been what a wonderful topic that's so relevant to our listener. The other thing is the ruralamericansurgeon.com. There's a contact. I'd love to hear the listeners experience with this too. So feel free. I do get those emails and read those emails that come through the contact page on our website. So please feel free to share that with me. So my story. is I had a patient that came in with a, it's like a say 60 year old patient with a good sized arm and has a melanoma in situ on her arm out here.
Dr. Randy Lehman (15:55):
It gets biopsied, basically completely removed by the biopsy of the primary care nurse practitioner and comes in with a tiny little scar and seeing me in a town of 900 people in a little clinic that I. held out there for consult, for surgery consult. So, okay. She needs a re-excision with a little wider margin. She doesn't even need a sentinel lymph node biopsy. My main concern is meeting her. Who does she know that I know? You know, like you usually do. And then when and where are we going to do this? And I was even kicking around, you know, we could almost just do it right there in the, in the office. That's sort of my.
Dr. Randy Lehman (16:36):
Perspective we get done with this conversation discussing all about this and then she throws at the end oh well actually uh my daughters want me to go to the melanoma institute in indianapolis which of course i never heard of you know and meanwhile i this is like i'm a couple years out from graduating mayo clinic and i'd done hyperthermic isolated limb perfusion treatment for melanoma, running people on bypass, doing in-transit Keytruda injections, and like all these other like, you know, thing, like extremely refractory recurrent melanoma and stuff. And this is literally the lowest that it possibly could be. I think that what you're talking about, it provides a bit of reassurance.
Dr. Randy Lehman (17:26):
To the primary care doctors and to the community for, again, stuff like that, you know, that just is nonsense. But the problem is I got this patient sitting in my office now. Now, what do I do as a doctor? Like if I try to explain what you know and what I know to her, it sounds like I'm giving a sales pitch or something.
Dr. Ronald Weigel (17:50):
Yeah.
Dr. Randy Lehman (17:51):
And then if something goes wrong, you know, even if it's just a little wound thing, even or God forbid she gets melanoma somewhere else or has some problem, then it's always going to be, oh, you know, we knew we should have went to the, you know, Melanoma Institute. So but if we're doing this accreditation and then. passing that on to the primary doctors and then maybe to the hospital administrators and they push it in the community too. I've had other patients where, and not just patients, but like friends and family and people that I know in the community. And I explain how I view my role in the whole ecosystem, right? Which is like I told you, there's all these rural hospitals closing.
Dr. Randy Lehman (18:32):
A lot of times they don't have surgeons. The difference between me and a surgeon in the city. is I'm just willing to do the same operation right there. It's literally the exact same thing. And I've had other people tell me, man, what you're talking about almost makes me wish that I needed surgery so that I could come, you know. Now they're bought in, you know. And the other lady is completely the opposite. So how can a young rural surgeon help to build trust and build... practice to the point where the people in their town, I mean, come on, you're a surgeon, like you're not going to tell them something that's against their wishes. Like you took an oath not to do that.
Dr. Randy Lehman (19:12):
But yet you're there, you got the training and you brought it to them. You brought the Mecca to Muhammad or you brought the mountain to Muhammad or whatever. And And now, how do you get that message across without sounding bad with it? Yeah, tip for the young practicing rural surgeon. I guess that's what I'm asking.
Dr. Ronald Weigel (19:32):
Well, so I think that honesty is the best way to approach that. I think in that particular case, you could say, well, look. I send plenty of patients who have complex care away that we're not capable of doing here. But the case we're talking about that you need is pretty much minor surgery. I don't believe that the place that you want to go to in Indianapolis is going to be able to provide anything else or additional. If you feel like you need a second opinion, have at it. That's your prerogative. And I'm happy for you to go wherever you want to go, but I'll tell you what you need. you need a wide excision with one-centimeter margins, and that's all you need.
Dr. Ronald Weigel (20:24):
And I can do it right here in the clinic. And I don't think you're going to get any other care. And by the way, in my training, I've taken care of very, very complex melanoma patients. And I believe we're up to date providing standard of care. If you want to go someplace else, obviously you're free to go do that. I don't think there's any other way to approach that problem.
Dr. Randy Lehman (20:51):
Yeah, I was taken aback. That was early on. I probably would approach it a little more like that now, but I kind of, I didn't like respond badly. I just kind of said, that sounds good. We'll set up a referral, you know, didn't even fight it. Okay. I love that. Um, if you, I love talking about surgery too. So if you had a few more minutes, um, we'd talk about a case you, do you have a preferred case that you want to talk about nuts and bolts of surgery?
Dr. Ronald Weigel (21:19):
I, you know, whatever you think your audience is interested in hearing about. Um, I've certainly taken care of a lot of. patients in rural communities. And as we've said, a lot of these patients have different priorities. And so the question is how to modify your approach based on what it is they're interested in having done. So whatever you think your audience is interested in hearing about.
Dr. Randy Lehman (21:50):
Yeah. Well, do you have any particular memorable case that sticks out? Somebody that came to you in your referral center from a rural environment and was like, you'll never believe this.
Dr. Ronald Weigel (22:01):
Well, I don't know if it wouldn't believe it. There were a lot of patients that I've taken care of who came from rural communities around Iowa and around rural Illinois. You know, I sometimes you end up doing things that you might not do if the patient was local. You know, so, for example, I can remember a woman who was sent to me with a very frustrating clinical problem that I'm sure you and others have had to deal with, which is recurrent breast abscess. You know, it's a very. relatively common but complicated problem. And you try to do, you know, you get this patient who's had, you know, three or four or five I&Ds and courses of antibiotics, and they keep getting
Dr. Ronald Weigel (22:56):
Some of them have even had, you know, excision of the duct and sort of a pie-shaped out to the, from the nipple out to try to remove that whole area that keeps getting reinfected and they keep getting reinfected. And I, you know, there have been a couple of women, one of whom I can clearly remember. who was just totally fed up with, you know, multiple recurrent infections and came from a rural community and got sent. And, you know, what I offered her was, I said, the thing that will guarantee this is completely gone is if I do a central breast lumpectomy, basically remove the nipple and areola and just make an elliptical incision around that.
Dr. Ronald Weigel (23:39):
Take out all that fibrotic tissue and the nipple and areola is gone and close it up. And that's the only thing I can guarantee it won't come back. And so I've had to do that a couple of times and just women who live so far away, they just don't want to keep coming back for yet another breast infection. So again, it's altering how you would approach things. for patients who are in these rural communities.
Dr. Randy Lehman (24:04):
Yeah, I love that. So I have a patient that I'm dealing with who had a kind of like an excision sort of the abscess cavity by another surgeon, came back, then I did something a little bit more like. Not exactly the pie-shaped thing that you're talking about, but of course it's going to be like central, this type of problem. If it's an abscess out to the side, it's not a problem usually.
Dr. Ronald Weigel (24:26):
It's nipple, nipple and areola classic infection.
Dr. Randy Lehman (24:30):
Yeah, and she did not heal. perfectly and but we're kind of still limping her along and i'm there for so but i give her that as the the next thing if if she wants something i we haven't actually done that but if you did that would you um do a transverse incision kind of at the borders of the areola and then going about a three to one out to the side and then um yeah take everything down, and then you just close it up like 3-0 Vicryl, 4-0 Monocryl, just like you would a lumpectomy, but including a skin paddle?
Dr. Ronald Weigel (25:04):
Yeah, that's exactly what I have done. And I've had that result basically cure the problem. And so, yeah, I mean, breast surgery has been interesting. When I was trained to always make a transverse incision. If you're doing cancer, you're doing a lumpectomy, make a transverse incision basically over the cancer, which I did for many years. But I found out that that works well, first of all, for cancers in the superior part, you know, north of nine to three to nine o'clock, the superior part of the breast that works pretty well. I do always do an ellipse.
Dr. Ronald Weigel (25:43):
And I find it heals better looks better with a bigger incision people want to make a small incision our residents you know resident so I say no we're making a bigger incision and it take and I do an ellipse directly over the cancer like if it's a wire loc or something like that I find that works better but then the inferior part of the breast I think I've learned that a radial-oriented incision looks much better because it pulls the breast together and you maintain the global shape of the breast. If you make a transverse incision in the lower part of the breast and try to close it, it often pulls the nipple down. It doesn't look as good.
Dr. Ronald Weigel (26:22):
And so radially, inferiorly, and transverse superiorly. Yeah,
Dr. Randy Lehman (26:27):
So let's riff off this. So basically, I've been told that same thing, but specifically 5 to 7 radial. And then I was also instructed from above 5 to 7 o'clock, go, it's transverse up top, but curvilinear otherwise. What do you think about that?
Dr. Ronald Weigel (26:47):
Yeah. I've not done curvilinear. I've done inferior part of the breast. I've done more of a radial type incision. And again,
Dr. Randy Lehman (26:55):
I take it- And that's anywhere below three to nine o'clock.
Dr. Ronald Weigel (26:58):
Right. And then if it's north of upper part of the breast from three to nine o'clock, then I make a transverse incision. And again, I do it with an ellipse.
Dr. Randy Lehman (27:07):
Which I guess at three and nine o'clock is still a transverse incision, radial incision. Right. Yeah. And when you do your ellipse, so say you had a three centimeter palpable lump that you're taking out, how big would you just roughly estimate that your incision needs to be? And then how wide do you make your ellipse?
Dr. Ronald Weigel (27:28):
Well, first of all, if it's cancer we're talking about and it's three centimeters, you probably should consider doing neoadjuvant treatment, right, to shrink that down. I probably would offer, I'd get them to see medical oncology and talk about neoadjuvant treatment beforehand. But larger tumors, yeah, I probably would tend to make an ellipse where the center of the ellipse was probably two centimeters. and then taper that over the course of maybe four or five centimeters. And because you've got to get a clear margin, and depending upon how superficial it is, if it's the more superficial it is, the wider I probably would make the ellipse.
Dr. Randy Lehman (28:16):
And you leave that skin paddle attached all the way down to the underlying? Okay. So then it helps you with orientation.
Dr. Ronald Weigel (28:23):
Yeah, exactly right.
Dr. Randy Lehman (28:25):
And if it's deeply seated, then you take just a little sliver of kind of normal breast tissue down to where the mass is and keep it attached?
Dr. Ronald Weigel (28:34):
If it is, you're talking about a deeper lesion.
Dr. Randy Lehman (28:38):
Yeah, like, yeah, the lump is, you've got.
Dr. Ronald Weigel (28:41):
I'd still make an ellipse and then as I dissect downwards, I would go wider.
Dr. Randy Lehman (28:48):
Okay.
Dr. Ronald Weigel (28:49):
So that breast tissue would be closed over the top and then often it'll, because sometimes if you make it too wide or it's really deep. the skin can get stuck down onto it and that doesn't look so good. But you can pull some of the, I'll sometimes, if I have a, the other thing I'd always do is I always do shave margins. I take additional north, south, east, west margins and set them as separate margins. I find that really significantly reduces the need for re-excision.
Dr. Ronald Weigel (29:19):
So if the primary tumor because you know when they cut this and they ink it there's a lot of handling it's all that fat and they push that inked fat right down to the tumor when they cut it and i've had plenty of examples where that it's clearly how it's processed that's making it look like it's got ink on tumor but then if you take separate margins and send them separately
Dr. Ronald Weigel (29:45):
You can see that the margins are clear because they'll say you have six total margins what i'll do is once i do the lumpectomy and send that specimen orient it send it then i sample the lumpectomy cavity so i'll send separate margins i don't orient it i just take separate margins because when i'm doing it i'm saying this is just normal fat normal breast tissue and fat
Dr. Randy Lehman (30:09):
And i'm not orienting it i'm saying this is the margin and when it comes back with no cancer in that it proves my margins were clear sure but that's six different jars right well um or how many like anterior posterior left yeah primary lump in north south east west so five specimens So there's no deep margin or superficial margin?
Dr. Ronald Weigel (30:35):
Not usually, unless it is a re-excision for a positive margin. Then sometimes I might label things separately. But usually I just take superior, inferior, lateral, and medial and send those.
Dr. Randy Lehman (30:52):
Okay um just for a few more minutes on this if i like to use uh as far as like Army-Navys you know for retraction and i like to use a silk stitch sometimes and throw it in the lesion and use that for my retractor like i throw a figure eight and put it on a tag any other tips or tricks uh for not touching your specimen so much
Dr. Ronald Weigel (31:13):
And preserving what margin you can and you're saying make the incision a little bigger possibly but still working in a small space and trying to be thoughtful about that yeah so the way i have always so whenever i operate i'm operating with a resident and so the resident is you know the majority of this physically so what it allows me to do is I usually put a skin hook on the skin and I use a metal Yankauer in the other hand. And with that Yankauer, I can push the specimen away and let the resident use the Bovie to dissect down to the, around the lesion.
Dr. Ronald Weigel (31:56):
So I usually just push the specimen with a Yankauer and then hold the skin away with a skin hook. And I find that works better for me. And I usually don't. put anything on the specimen it just i just push it with the Yankauer because i think if you clamp it you're going to rip the you know it's going to be more likely that there's going to get ink onto the tumor because usually that's a classic thing though what you're talking about the attending doing the dissection with the suction you know that's just standard
Dr. Randy Lehman (32:32):
That's great. Is there anything else, like something that you think you do that maybe you don't see everybody doing, but it's an interesting tip that you could, I love tricks and tips for surgery that you could share with me?
Dr. Ronald Weigel (32:43):
Well, you know, I've done a lot of parathyroids. I've done a lot of thyroid surgery and a lot of breast surgery. You know, I don't know. It's interesting because working with the residents, there's always different things that they've picked up. that they've understood or figured out. I have my own way of doing a thyroidectomy, just sort of mechanical step one after the other, you know, find the nerve, ligate the superior pole. One thing I think that little tiny pearl trick that I don't know how this came about, but why I recognize this, but a lot of times people want to put a retractor in into the thyroid and to pull the strap muscles away.
Dr. Ronald Weigel (33:28):
But what I have found is that if you put a Babcock on the thyroid lobe and lift the thyroid up before the retractor goes in, the exposure is so much better. And I don't know why that is. But those are these little things where if you set it up that way, all of a sudden, it's one of those attending things where here the exposure looks so great and the resident with their by themselves think they're doing exactly the same thing, but it doesn't look the same and it doesn't look at the same exposure.
Dr. Randy Lehman (33:57):
You're kind of pulling it out and making it 3D. before you put you're kind of pulling it out and making it 3d rather than like just putting your retractor you're kind of pushing it down exactly and you're talking about a lateral retractor right which yeah you're talking like a goiter that you would use for that or an Army-Navy or what Army-Navy yeah put an Army-Navy in and after you deliver the thyroid up pulling it it helps to do that exposure into the back
Dr. Ronald Weigel (34:24):
And the other thing is, you know, the whole key of avoiding a complication in thyroid surgery, well, obviously, there's no hematoma, so it's got to be tried. But it's preserving the nerve and preserving the parathyroid glands. And a lot of times when people are dissecting the parathyroid, what I see residents doing is they want to lift it up because they want to bring it up, but you don't. You want to push it away. And so having it in your mind that the whole idea of this parathyroid is to push it down and away so the thyroid can come up, that's how you preserve the blood supply for the parathyroid.
Dr. Ronald Weigel (35:01):
So there's just those kind of little nuances that you think about after doing this for 30 years that I'm not sure residents pick up immediately.
Dr. Randy Lehman (35:11):
Yeah, that's exactly what I was kind of hoping. Last question on that, and then maybe we'll move on, is that if you're going to do, so right at this particular moment, I've done a couple parathyroids, a couple thyroids early on in my practice, but the volume really wasn't there for me to be comfortable with it. And so I'm not at this moment doing them. I'm just sending them out. I'll see patients if they want to talk about it. at some point, I think we'll get to the point where we'll probably bring it on again. It may be in a place where I bring on a partner and then maybe we do them all together for a while.
Dr. Randy Lehman (35:43):
We keep our own volumes up and things like that. But we have to have a lot of things have to be going right. And it just hasn't been easy. And part of the problem is that it's better if you can do thyroids and parathyroids. But like for parathyroids, we don't have the one hospital. well, any of the hospitals, we don't have parathyroid hormone intra-op monitoring. And I had to, I went to the lab, I said, can we get this? And then I, they said, yeah, we can, but it's a huge, like you have to replace your whole machine. It's not like it's a one little standalone thing that you can get in the lab. So your whole lab machine that runs everything.
Dr. Randy Lehman (36:20):
So obviously it was like non-starter. We can't do it. We also didn't have nerve monitor. So then you got to have, your anesthesia has to be willing to work with you. So where I was going with this is actually to focus on the nerve monitor. Would you do, like, do you think a graduating resident should go out and do thyroid, parathyroid surgery in a hospital that doesn't have a nerve monitor? I know this would be a crazy question 30, 40 years ago, but I'm just asking it.
Dr. Ronald Weigel (36:45):
Well, I trained 30, 40 years ago, so I never did nerve monitoring. And my own feeling about nerve monitoring, particularly for thyroid surgery for cancer, I'm convinced it can lead to doing the wrong operation, meaning you're pulling the thyroid up, you're doing all this dissection, and the nerve is not responding. if you're doing nerve monitoring, that could make you not take out the other side. So that patient's going to end up needing a reoperation. I never did nerve monitoring. I think it slows you down. It is inaccurate. And most studies who have looked at this, it does not prevent a nerve injury.
Dr. Ronald Weigel (37:28):
And in my own opinion, it causes... you to potentially not do a contralateral lobectomy because you're not getting the nerve to stimulate. So I never did nerve monitoring.
Dr. Randy Lehman (37:40):
Love it. That is the question or the answer I was, you know, only you could tell me so.
Dr. Ronald Weigel (37:46):
Well, I find the nerve. There it is. I know what it looks like. follow it up. It's not injured. And so that's worked for me for as long as I've been in practice. But I do think that intra-op PTH helps because, you know, if it's a well-localized adenoma and the level falls, you know, you know, you're done as opposed to doing a four gland exploration, which is perfectly acceptable. I have often done four gland explorations, biopsy the normal glands, prove I've found all four, tag their location with a little Prolene suture, took out the adenoma. That's a perfectly acceptable way to do it, but it takes a little longer.
Dr. Randy Lehman (38:28):
Yeah, that's the standard of care. So I had a patient like that, well-localized adenoma on preoperative imaging and classic presentation. mentor back home, but this is early out in practice. And I said, you know, I don't have PTH monitor. So I can, I think standard of care is four-gland exploration in this scenario. He's like, yep, it's four-gland exploration. I'm like, I don't think she really needs a four-gland exploration. Like I think a very high chance that there's going to be this single adenoma. And then I talked to several other rural surgeons and they said, yeah, we don't have that either. And yeah, you can do that. But like, what would you want if it was you?
Dr. Randy Lehman (39:10):
And she's straight up saying she wants to stay there and do the operation. And so then I was also told by these other practicing rural surgeons that they would not do that. They would just take out the adenoma and then. post-op, see them back with their parathyroid hormone check. And that is what I ultimately did in this particular case. And of course it worked out, but you know, you may have a 5% that it doesn't. And so what do you think about that decision? Bad decision?
Dr. Ronald Weigel (39:38):
No, I think it would probably be if I got referred a patient who had recurrent disease. And the surgeon out in the community removed a parathyroid adenoma, classic brick, you know, kidney bean, and pathology was confirmed. And they found the normal gland on that side, biopsied, normal parathyroid, and did not explore the other side. I would say that's acceptable. The thing I don't want is go to the other side, create a lot of scar tissue, not find any other glands. That is a much more complicated issue. So if you're comfortable, you can find the adenoma, you take it out. The other gland outside is normal. Take a little tiny pot scissored biopsy of that, send it for frozen, confirm, mark its location.
Dr. Ronald Weigel (40:36):
Close, that is probably acceptable. I have no problem with that as a parathyroid surgeon.
Dr. Randy Lehman (40:41):
Okay.
Dr. Ronald Weigel (40:42):
Particularly if they get preoperative imaging, in my experience, if the sestamibi scan, and I always do an ultrasound, not only for the parathyroid, but to document that there are no thyroid nodules because the last thing you want to do is operate. Then you find a thyroid nodule and it's cancer and you're doing a different operation with your plan. So I'll do an ultrasound, make sure there's no other thyroid nodules, confirm the location. And if the ultrasound and sestamibi gland location agree, they are 98% chance it's a single adenoma.
Dr. Randy Lehman (41:17):
Yep.
Dr. Randy Lehman (41:18):
Very good. But all of this nuance is why I decided for the time being, you know, that I'm not also busy enough doing all this other stuff. So, but, but everybody's got to decide for their practice. And this is where it like sounds like on your accreditation, you know, you can just say, well, those are two cancers that like. or maybe that parent thyroid cancer, thyroid cancer. We just don't do right now. We don't have to worry about the accreditation for that, but these are the other cancers that we do and everything. So I just appreciate you taking all this time. I think we're probably gonna have to make this into two episodes to get all the goodies in it.
Dr. Randy Lehman (41:51):
It was just wonderful. I just appreciate what you're doing with American College and thank you for joining us on the show today.
Dr. Ronald Weigel (41:56):
Thank you, Randy. It's been a pleasure and I wish you all the best. And just final note to your rural surgeons listening to this, you guys are doing an incredible job. It is a very difficult job. I don't think you're given enough credit and I hope you've got a referral base where you are, where you can call the big academic center when you need them without getting a lot of pushback. I know we try to build that here. I hope you have that in your location because what you're doing is really God's work. So thank you.
Dr. Randy Lehman (42:29):
Thank you. I appreciate it. And thank you also to the listener for joining us on this episode of the Rural American Surgeon. We'll see you on the next episode of the show. That concludes my conversation with Dr. Ron Weigel. Rural cancer care is a great example of what rural surgery is all about. knowing what we can do well locally, building the systems to do it well, and knowing when our patients need something that we actually can't provide. Thanks to Dr. Weigel and the Commission on Cancer for the work they're doing to make high quality cancer care more accessible in rural America. And thank you for listening to the Rural American Surgeon. I'll see you next time.
Timecode:
00:00 Part Two: Rural Cancer Care and 24/7 Coverage
01:12 Can a Hospital Without 24/7 Surgery Still Be Accredited?
02:01 Which Cancers Should Stay Local?
03:18 Investing in Rural Surgical Capabilities
04:14 Breast Reconstruction in Rural Practice
06:08 Rural Patients and Mastectomy Preferences
08:11 Listening to What Rural Breast Cancer Patients Want
10:14 How Accreditation Handles Breast Surgery Choices
10:57 Keeping Rural Surgeons Current as Standards Change
12:01 Developing Rural-Specific Quality Metrics
13:01 Why Rural Cancer Data Matters
14:12 How to Learn More About the Rural Accreditation Program
15:21 A Rural Melanoma Case and the Trust Problem
19:32 How Rural Surgeons Can Build Patient Trust
20:51 Transition to Surgical Cases and Pearls
22:01 Managing Recurrent Breast Abscess
24:04 Randy's Recurrent Breast Abscess Case
25:04 Incision Orientation in Breast Surgery
27:07 How Large Should a Lumpectomy Incision Be?
28:49 Using Shave Margins to Reduce Re-excision
30:52 Retraction and Specimen Handling During Lumpectomy
32:43 Thyroid Surgery Pearls
33:28 Improving Exposure During Thyroidectomy
34:24 Protecting the Parathyroids
35:11 Bringing Thyroid and Parathyroid Surgery Back to Rural Practice
36:45 Dr. Weigel on Recurrent Laryngeal Nerve Monitoring
37:46 Intraoperative PTH and Four-Gland Exploration
38:28 A Rural Parathyroid Case Without Intraoperative PTH
39:38 When Focused Parathyroidectomy Can Be Acceptable
40:42 Using Ultrasound and Sestamibi Together
41:56 Dr. Weigel's Message to Rural Surgeons
42:29 Closing Thoughts: What Rural Cancer Care Is About
