EPISODE 61
Defining Your Value & Protecting Your Time in Rural Surgery | Dr. Cate Straub Pt. 2
Episode Transcript
Dr. Randy Lehman (00:08):
I don't have to go into this level detail of the whole thing, but I'm just asking because this is literally the conversation that it's fun for me to have. That's what my whole show is. It's like the conversation I want to have, and then somehow I convinced you to have this conversation with me. So nobody to blame but yourself. Gotcha. So how does your first assist retract the duo medially while you're holding a Bovie cautery?
Dr. Cate Straub (00:31):
Well, they're both women. They're fantastic. And she just, I get into that initial plane. I just break down that initial peritoneal attachment myself. I just kind of get in there and then it kind of creates a little shelf for her to get her fingers into and she can just keep pulling it up and keeps adjusting. And I swear she has like 15 fingers because they're exposing everything beautifully. And so, and then sometimes that's not what I need to see, and I just take her fingers. And it's almost like having my own new retractor on the Bookwalter. And I kind of put her where I need her and I pull her back and then I get going again.
Dr. Randy Lehman (01:11):
I mean, once you get a little bit of traction, so to speak, with the same person over and over, then it's easy. But do you have any way to teach a new assistant how to be a better assistant? Because I have one thing I tell 'em to be like Gumby, some people get that and some people don't,
Dr. Cate Straub (01:32):
But
Dr. Randy Lehman (01:32):
Any other tips like that and how you can, because everybody has this same problem whether you're doing Whipples
Dr. Cate Straub (01:37):
Or
Dr. Randy Lehman (01:37):
You're just doing lap.
Dr. Cate Straub (01:39):
I remember when, so for the longest time when I started doing Whipples, I was using one of my partners who soon afterwards retired, and in his retirement, he offered for us to maintain his malpractice insurance so he could keep assisting us with a variety of surgeries. My one partner used him for Ectomies. I used him for Whipples, and we'd call him in the middle of the night for traumas if we needed him. And eventually he's like, Kate, I'd really like to really retire. I've got some grandkids and I'd like to travel the world with my wife, and you are good enough and should do this with first assists. And I was terrified. How was I going to do that the first time? And so I kind of found the perfect first case that non-cancer, there's going to be no vein involvement. There's going to be not a lot of hyper vascularity or desmoplastic tissue and things like that.
(02:28):
And I just said, this case is going to take a really long time, and we just had to be patient with each other in that way. I've worked with a few different RFAs and eventually I told the, or these are the two, two that I have to use that listen to me, that understand and that I can work with. But I have to tell you, it's hair raising. When you're in rural America, you don't get your own team for every case. You get whoever's there, and they may be travelers and maybe they've seen a Whipple before and maybe they haven't. And you really have to embrace your role as a teacher more than anything else. You can't be upset that they're not reading your mind.
Dr. Randy Lehman (03:14):
Yeah. Okay. So patience and communication. Okay.
Dr. Cate Straub (03:20):
I mean, that's really everything, right? I mean, I can't sit here and tell you of my S qualities. This is how I tell them where to put their fingers. No, you have to be in the moment and then be like, no, this is what I need from you, and kind of adjust it. Well, that
Dr. Randy Lehman (03:33):
Gumby thing, I mean, that's literally something that I tell everybody. And then if I have to explain it like you move when I move, you don't be so rigid, but then stop and don't move again.
Dr. Cate Straub (03:43):
Yeah. No, you have to. And eventually you work on their ability to anticipate and eventually you let them grab the portal vein.
Dr. Randy Lehman (03:53):
Okay. So maybe we talk about vein recon in a minute, but so we got your Kocher maneuver completed. How do you know that your Kocher maneuvers completed?
Dr. Cate Straub (04:05):
Oh, I should be feeling the spine. I should be up and over that vena cava all the way through, and I should be almost, if not completely through the ligament of Treitz. And the thing is, you want to do it all upfront when you are fresh and you're excited about your case and not realize that four hours later when you're coming across your uncinate and peeling it away from the SMA that you just didn't quite do enough at the beginning and then have to redo it. So much of what we do is completing it, getting a step done through completion on the first go around. And so yeah, your Kocher maneuver is complete when you go from your ligament of Treitz up to your portal all the way over the IVC and you're back to the sorry ligament of Treitz up to the porta over the IVC to the aorta.
Dr. Randy Lehman (04:48):
Okay. I never really considered doing Whipple as part of my practice. So I think I graduated with a nine pancreas case as surgeon junior
Dr. Cate Straub (05:00):
And
Dr. Randy Lehman (05:01):
Had, but we were HBB Center, and that doesn't count, obviously the ones that I didn't do a meaningful part of the case that I put as first cyst, but man, it's starting to take me back a little bit. So I'm coming up on six years out of residency and
Dr. Cate Straub (05:19):
Well, I got to tell you, knowing those techniques, I mean as a rural surgeon being comfortable in that part of the body helps you with you're perforated to use when they come in, you got to fix them. And it's even helped me through a couple really challenging traumas, gunshot wounds and things like that. The Kocher is the beginning of a total medial visceral rotation to that side and how you evaluate the IVC. And I think it was when another surgeon called me in to help with a case, and I said, I'm used to getting called in anytime somebody looks at a pancreas wrong in the or, but this had nothing to do with the pancreas. And I didn't say, why am I here? But I was curious, and they said, if you're a pancreas surgeon, you're kind of the queen of the lesser sac if I need you, the queen of the lesser.
(06:05):
And I was like, queen, the lesser goes, that makes sense. No, they were having, a vascular surgeon was in a dicey AAA and they needed supraceliac access, and they were just like, we want somebody who's our vascular surgeons don't go up there anymore. So they were like, we want you here to do that. And my partner and I just repaired through and through injury to the vena cava from a gunshot wound and got her shipped elsewhere afterwards. But it's knowledge of that that gives you a comfort level and you know how aggressive you can be and how far things can go and what it's supposed to look like.
Dr. Randy Lehman (06:44):
Do you have a lot of that gunshot wound trauma in Wenatchee
Dr. Cate Straub (06:48):
Wenatchee? No. So when it happens, it's pretty terrifying.
Dr. Randy Lehman (06:54):
Sure. Yeah. Okay, so let's get back to the case. So
Dr. Cate Straub (06:59):
Your
Dr. Randy Lehman (07:00):
Ization is complete. Next is
Dr. Cate Straub (07:02):
Next is opening up the lesser sac. You pick up the stomach, you pull down on the colon, you preserve your gastroepiploic artery, and you enter your lesser sac just along that greater curvature and allow the whole omentum and colon to fall down into the lower part of the abdomen, and you open up that lesser sac along the greater curvature, sort of just up past the incisura. And then you should be just staring at your beautiful pancreas at the bottom of the lesser sac. I mean, there's some adhesions in there. Sometimes
Dr. Randy Lehman (07:33):
Some
Dr. Cate Straub (07:33):
People open
Dr. Randy Lehman (07:33):
The lesser sac the other way and let the colon fall down and the omentum go up, or
Dr. Cate Straub (07:38):
Yeah, it just creates too much tissue in the upper portion of the abdomen where I'm working the way I do, it just allows all that momentum to be in the lower portion of the abdomen. And I'm not trying to retract all that while I'm working on the pancreas,
Dr. Randy Lehman (07:54):
But some people do that. Right.
Dr. Cate Straub (07:57):
Not in my practice, but I mean, I'm not with every HPB surgeon.
Dr. Randy Lehman (08:00):
Yeah.
Dr. Cate Straub (08:00):
Okay.
Dr. Randy Lehman (08:01):
Sounds good. I'm kind of operating on memory here. So
Dr. Cate Straub (08:04):
Anyway, you can see, I could see that you're back in your chief year reliving it right now.
Dr. Randy Lehman (08:08):
Yeah, exactly. So carry on then.
Dr. Cate Straub (08:10):
Yeah. So from there, you should be able to hold up your transverse mesocolon and see your middle colic pedicle coming down, and that should sort tangentially sort of right on top of the SMV. And so what you're going to do is find the right lateral side of your SMV where it's kind of running right along that snit process, and you want to get right on that vein and just sort of trace it all the way up to the inferior border of the pancreas and where it starts diving underneath, you open up the inferior border of the pancreas enough so that you're not just digging a deep hole and then you start lifting up that inferior border and just bluntly making that terrifying tunnel underneath the pancreas where there should not be any bridging vessels, and there frequently is not as long as the cancer is not super close to that area, and you can usually make your tunnel, and for me, it's just a vein retractor on the inferior border of the pancreas and Metzenbaum scissors just sort of occasionally snipping these wispy things and just bluntly dissecting all the way underneath to the superior border.
Dr. Randy Lehman (09:18):
I
Dr. Cate Straub (09:18):
Remember
Dr. Randy Lehman (09:18):
A curved pean clamp pointing upward. Do you
Dr. Cate Straub (09:21):
Use
Dr. Randy Lehman (09:21):
That or mostly
Dr. Cate Straub (09:22):
You're looking, do you can do that too? Sometimes I get a little mixture, those big right angles in there and kind of just sweep it back and forth. There's a lot of different ways to do it, but I think, again, when you have to get used to the efficiency of not having a lot of talented assistances, not to put down my RFAs, they're amazing, but you do a lot of dissection with scissors, use your scissors as your blunt and sharp instrument because it just keeps you efficient. You treat it like a pean that can also cut things.
Dr. Randy Lehman (09:51):
Yeah. Okay. And so then say it's stuck. Yeah.
Dr. Cate Straub (09:59):
Then I have to figure out how stuck is stuck and is it stuck in a way where this is unresectable? Occasionally we do back out, I back out last week from one that was wrapped around the hepatic artery, or is it stuck in a way where it is resectable? Am I going to be able to do a vein resection or is there a chance that all this is is a desmoplastic reaction from the chemo effects on the tumor? And it's just sort of post-inflammatory changes that have it be stuck, and that can be very, very, very hard to tell.
Dr. Randy Lehman (10:30):
Do you use frozen to help you differentiate that? Sometimes
Dr. Cate Straub (10:34):
You do. Yeah, you can though honestly, there's limitations to what frozen can tell you. I mean, if there's vague ayia, you don't know if that's because it's desmoplasia or if you're dealing with real cancer. If it's cancer, it's cancer. If it's not, it's not. But there's a lot of InBetween that frozen gives you, and you just have to know what you're going to do with that answer when you get it back. I may need 20 minutes to think about it.
Dr. Randy Lehman (10:55):
Sure. That patient that has an encased R hepatic or I mean hepatic artery, so they're it, they're not going to ever have any operation anywhere else?
Dr. Cate Straub (11:09):
No. I mean there are some people that are doing some pretty dramatic things in that regard. However, this gentleman had already had a significant amount of liver dysfunction related to his obstructing tumor, wasn't getting good recovery of that liver function even with stenting, and so wasn't going to deal without hepatic arterial supply.
Dr. Randy Lehman (11:26):
Right. Okay. Then say that it's borderline stuff. What sort of vascular reconstruction will you
Dr. Cate Straub (11:38):
Undertake?
Dr. Randy Lehman (11:39):
Yeah,
Dr. Cate Straub (11:39):
First and foremost, when I'm evaluating patients, if I say hands down, you're going to need a portion of your vein removed, I'm probably sending them elsewhere. I'm sending them somewhere where they're ready because I think that every pancreas cancer case, whatever the imaging shows you, it's going to be worse when you get in there. There's no time where I'm surprised at how great it is after seeing concerning imaging findings. So the ones that I'm taking to the or the ones where either I don't think it's going to be on the vein based off of the imaging or if it is in a favorable part of the vein. And for me that is portal vein or proximal SMV I do not operate on lower SMV down by where it starts to send off its tributaries that is just too narrow a vein, and you really worry about boxing too many branches from the small bowel. So I'm picky about which of those cases I keep. What I can do is I can get proximal and distal control on the portal vein, SMV, IMV and middle colic veins utilizing usually just red rubber, not red vessels, vessels,
Dr. Randy Lehman (12:43):
Yeah.
Dr. Cate Straub (12:44):
Folded back on themselves and use my vascular set to either get good clamps on all of those or put a Satinsky clamp just sort of around just that knuckle that's frequently stuck to the vein and then cut it and then suture it back up and cross my fingers.
Dr. Randy Lehman (13:06):
But you patch 'em.
Dr. Cate Straub (13:07):
I don't patch. No. Again, actually, a lot of the data shows that you don't need the vast majority of these side bite resections or even full thickness portal vein resections don't require much of a patch. You can really mobilize and kind of pull things together. I've never had to patch, but again, I'm picky on who I keep.
Dr. Randy Lehman (13:27):
Yeah, we're only talking about ones that are borderline, and then it's sort of like you weren't planning on doing a resection, but then you ended up doing it, and so when you're going to close that vein, you're closing it transversely.
Dr. Cate Straub (13:42):
It really kind of depends, and most of the time, I'm not closing it transversely, just the way it comes off, you're closing it longitudinally. You're seeing mild narrowing to that vessel. I've never had issues with postoperative DVTs or I mean portal vein thrombosis and things like. Yeah.
Dr. Randy Lehman (14:00):
And then afterwards, then, so you heparinized them before you get started on that part
Dr. Cate Straub (14:07):
Of the case? Yes. If I'm getting full on proximal distal control and I'm tightening things down, they're getting heparinized. If I'm just putting a satins ski across and there's still good flow throughout, I'm not always heparinized them
Dr. Randy Lehman (14:18):
And post-op. Then what do you do
Dr. Cate Straub (14:20):
With heparin post-op? They get started on Lovenox right away. You get a doppler of the flow.
Dr. Randy Lehman (14:26):
Prophylactic Lovenox?
Dr. Cate Straub (14:27):
Yeah, just prophylactic Lovenox initially, but we do trauma, not trauma dose, sorry, cancer dosed prophylactic Lovenox, and then usually get Doppler in the first day or two just to make sure that there's good flow.
Dr. Randy Lehman (14:40):
Tell
Dr. Cate Straub (14:40):
Me
Dr. Randy Lehman (14:41):
What you mean by
Dr. Cate Straub (14:42):
Cancer
Dr. Randy Lehman (14:42):
Dosed prophylactic
Dr. Cate Straub (14:43):
Low. Well, usually, I mean, it's 40 a day for regular, and I do 30 twice daily for the vast majority of cancer patients.
Dr. Randy Lehman (14:50):
Okay, got it. So 30 BID Lovenox.
Dr. Cate Straub (14:54):
Yeah. Okay.
Dr. Randy Lehman (14:55):
And
Dr. Cate Straub (14:55):
They go home on that.
Dr. Randy Lehman (14:57):
Okay. For a month.
Dr. Cate Straub (14:59):
Yeah.
Dr. Randy Lehman (15:00):
Okay. So for this listener who is concerned about oral boards,
Dr. Cate Straub (15:08):
Yeah.
Dr. Randy Lehman (15:10):
Tell me about what they need to know about the topic of resectability of pancreas cancer in 2026. Should they be asked about it on an oral board
Dr. Cate Straub (15:24):
Scenario? Oh God, that sucks. It sucks because I mean, I still think there's a lot of people doing a lot of very heroic things in regard to pancreas cancer resection out there, and I don't want to belittle what people are capable of doing.
Dr. Randy Lehman (15:40):
First, let me pause this just one second. Tell me where we came from maybe and then where we're at now and what is the middle of the road? Right answer.
Dr. Cate Straub (15:53):
There's no right answer. So where we came from when I was training and maybe when you were training, it all had to do with a degree of involvement of the portal vein or SMV, and if it was greater than 180 degrees, it was probably unresectable, and if there was arterial involvement, it was unresectable. And obviously if there's metastatic involvement, it's unresectable. And now I've learned to not really call anything unresectable if it just involves the portal vein or SMV. What I do is I always try to follow, when I send patients elsewhere for second opinions, I either reach out to the surgeons or I review their notes or what I'm seeing time and time again is, Hey, we'll just give you chemo and see what happens. We're not calling anything unresectable in regard to portal vein anatomy now, and unfortunately, a lot of those patients, they had aggressive tumors to begin with and they just don't go on to reform resection following neoadjuvant.
(16:53):
So you say, this might be resectable, let's give you chemo, but the most of those patients don't go on to getting it. So things that I still consider unresectable is involvement of the celiac plexus or the SMA or the aorta that is just unresectable. But when it comes to venous resection, people are being more and more aggressive with what they're willing to offer, and I don't think anything is necessarily considered unresectable. That being said, most of those people don't go onto resection just because they have aggressive tumors to begin with. So what do you say on the boards if you get that question?
Dr. Randy Lehman (17:34):
I mean, they may just say, well, you got this pancreas mat mass, this looks like cancer on ct. They make you work it up a bit. So then I would say the right answer is probably an EUS with a biopsy,
Dr. Cate Straub (17:46):
EUS with biopsy. And once it's biopsy proven, they get neoadjuvant chemotherapy and you go from there.
Dr. Randy Lehman (17:51):
Yeah. Then lab wise, they got to get some special labs on a workup,
Dr. Cate Straub (17:56):
C 19 nine, preferably done both before and after they get their ERCP. They always get it beforehand, but C 19 nine is artificially elevated by biliary obstruction. So you want to get a new baseline after their bilirubin has dropped down,
Dr. Randy Lehman (18:11):
And then say that the mass was touching the portal vein over just a 30 degrees of the portal vein. Okay. Yes.
Dr. Cate Straub (18:20):
So
Dr. Randy Lehman (18:20):
Those people are and always have been resectable. And so then the oral board person should say that they get the workup and the treatment and then surgery just like that as long as there's no progression. But then if they got a, I don't think they would give you this patient, but say it was three quarters the way around the portal vein, so they're probably not going to give you that.
Dr. Cate Straub (18:51):
No, they're not going to. And I have to say really as I'm thinking through your thought processes here, I really don't love the term borderline resectable. I feel like things are either resectable or they're not resectable, and if they're resectable, it all depends on how they do on chemotherapy and who the right surgeon is to attempt that resection. Borderline resectable, I feel like should go the way of the dodo.
Dr. Randy Lehman (19:12):
Sure. Okay. Thank you for clarifying that. And then the last thing I wanted to do for the listener is say somebody's never put a vessel loop for vascular control around a vessel before. Tell me exactly how to do that.
Dr. Cate Straub (19:29):
So what you want to do is be as on the vessel as possible for all of this. I think for when it comes to these bigger vessels, like the portal vein, it's a little terrifying to be vessel on. You always want to be a little bit farther away, but that's where the dissection plane is. So you want to be right on the vessel. You want to come around the vessel and sort of be able to spread with your right angle or your tonsil to make sure that you have a nice plane underneath. And then you're going to pass your red vessel loop around. You're going to put your clamp back under, you're going to pass the red vessel loop again, so it goes around twice. And then you're going to be able to cinch up on that with a hemostat and occlude the vessel, and you're going to do that on every vessel that's coming in and out of your area of concern.
Dr. Randy Lehman (20:10):
So double pass with the vessel loop and then to keep it while you're setting up all of your five vessels that you're going to isolate,
Dr. Cate Straub (20:18):
You just keep it loose, you keep them on news, and then you decide as a team, you're ready to go forward with that.
Dr. Randy Lehman (20:26):
Take your right angle, pass it right under, pull up on the loop that you just passed around, and then clamp all four pieces together. Okay. This is how, it's my show, Kate. So if I have to ask these stupid questions because I really want to, then I guess it's my right. Thank you for playing along. Okay, great. So then you're going to transect your stomach first, right?
Dr. Cate Straub (20:53):
Yeah.
Dr. Randy Lehman (20:54):
And you're going to do that with a
Dr. Cate Straub (20:57):
Stapler A Yeah, GIA or now that we have to call them linear cutters, but yeah, gi a stapler, the blue lid. You use open
Dr. Randy Lehman (21:05):
Stapler. You don't staple open surgery with laparoscopic stapler.
Dr. Cate Straub (21:10):
No. Some
Dr. Randy Lehman (21:11):
People
Dr. Cate Straub (21:11):
Do
Dr. Randy Lehman (21:11):
That because there's
Dr. Cate Straub (21:12):
Three loads of
Dr. Randy Lehman (21:12):
Staples on each side.
Dr. Cate Straub (21:14):
No, the only time I do that is if I happen to be doing an open distal. I really like the laparoscopic stapler to staple the pancreas there because you in general have a really, you can sequentially squeeze down on it really, really nicely when you're doing that, and it kind of allows the pancreas juices to go out, the edema to go out to get a nice better seal on that. So when I'm doing a distal, I really love the laparoscopic stapler. Yeah,
Dr. Randy Lehman (21:40):
I worked with some surgeons who like to use laproscopic staplers on everything. They have three rows of staples on each side instead of two,
Dr. Cate Straub (21:48):
But
Dr. Randy Lehman (21:48):
I don't know if that's been proven or whatever,
Dr. Cate Straub (21:50):
So
Dr. Randy Lehman (21:51):
Probably not. I'm sure it's not. So blue load, just transect, however, what length of a stapler are you normally use and how many loads do you normally have to use to
Dr. Cate Straub (22:01):
Get across your stomach? Well, first and foremost, I do a traditional Whipple. I don't do pylori preserving, so I'm going just above the Pylori, but the vast majority of the time it is a single fire of linear cutter of 75 with a blue lobe.
Dr. Randy Lehman (22:16):
Alright. And then you're going up to your porta next?
Dr. Cate Straub (22:21):
Yeah, I've usually done my whole port because again, I don't want to start transecting things until I know everything is resectable. So gallbladder
Dr. Randy Lehman (22:27):
Comes down first,
Dr. Cate Straub (22:28):
Gallbladder comes down, you open up the porta, you identify all of your hepatic arterial anatomy pretty much all the way back to the celiac. So you can pull those lymph nodes over. And then the next step is to identify your GDA and take your GDA and usually your portal vein once you take your GDA between clamps. And one trick is the dreaded GDA bleed, which I've seen twice and is terrifying. And thankfully both patients survived. IR is going to be your friend for controlling that bleed. And you can help them a lot by putting a clip on that GDA pedicle because then they can see that when they're in there and they can really identify if that bleed is not actively bleeding where they need to be throwing their coils. And so right under that GDA, you should be staring at your portal vein and then you can kind of connect your tunnel from above and below without too much difficulty come around the portal vein with a red vessel loops or separated away from everything else and kind of identify where that is.
(23:29):
And once you're there, that's when you transect the stomach. Then I transect the bile duct, I send a frozen section on every bile duct. Then I transect the pancreas, which is a challenge and always send a frozen section of the duct of the pancreas as well. And then you really want to make sure when you're transecting your pancreas that you're giving yourself an especially good landing pad for your anastomosis. You don't want to be cutting through it tangentially, leaving yourself a sort of like something that's going to be hard to then sow to. You want to make sure that as you're trying to cauterize any bleeders on the edges of the pancreas, that you're not cauterizing too close to the duct. You want your duct to be fricking beautiful when you're getting ready to sew it again. So you just try. What I usually do is have my assistant put a EC over the distal pancreas, the part that's going to become part of that anastomosis. And while I'm getting my frozen section and controlling bleeding on the specimen side of things, she's just holding consistent pressure. And in all the time it takes to do that, that will stop the vast majority of slow oozing from that distal edge because she's been putting this constant pressure on it. And then hopefully really limit the amount of cautery I need to do to that distal edge and keep that as fresh. Do you need
Dr. Randy Lehman (24:44):
Some bipolar for the cautery if you need to, or do you just use straight cautery?
Dr. Cate Straub (24:50):
I use straight cautery if it's bad enough, especially around the edges. I'd rather use stitches than just keep burning the crap out of the pancreas. I don't really want that at all
Dr. Randy Lehman (24:59):
Landmark wise for all three of those transections for easiest ones stomach. How far above the pylori do you go?
Dr. Cate Straub (25:07):
I'm like a centimeter or two above the pylori. As long as the tumor is totally uninvolved in that area, I'm just And how do you know where to
Dr. Randy Lehman (25:13):
Transect the bile duct? Well,
Dr. Cate Straub (25:16):
Especially if you're just dealing with a pancreas cancer, not a cholangio. I don't do a ton of cholangios here, but usually I'm just kind of at that superior border, maybe right at where the duodenum comes into where the bile duct comes down to the duodenum superior border of the pancreas
Dr. Randy Lehman (25:35):
Relative to the cystic duct.
Dr. Cate Straub (25:37):
Well, the cystic duct is a very variable insertion along the common bile duct, so it's hard to say relative to that. But sometimes being at an area, especially if you have a smaller bile duct, it can be helpful to be up by the cystic duct. You can almost, when you're doing your reconstruction, you can almost complete that common septum between the common bile duct and the cystic duct and use that to make a slightly larger anastomosis for your bile duct.
Dr. Randy Lehman (26:06):
Okay. So would you say that it's commonly around the junction of the cystic duct in the,
Dr. Cate Straub (26:11):
I'm a little below the junction of the cystic duct duct
Dr. Randy Lehman (26:15):
With
Dr. Cate Straub (26:16):
That, but I mean, again, that's variable. The cystic duct can attach in all the way down in the pancreas.
Dr. Randy Lehman (26:23):
And then for when you decide where to transect the pancreas,
Dr. Cate Straub (26:27):
You
Dr. Randy Lehman (26:28):
Have, yeah, go ahead.
Dr. Cate Straub (26:30):
So the best place to transect the pancreas is over top of the portal vein. I mean, I keep it simple with patients. I draw my pictures and I say, this is where I transect the pancreas. If your cancer lives on this side, you get this surgery, who lives on that side? Side, you get that surgery. But a reason why it's best to transect over top of the portal vein is the pancreas is always thinner there. You are not dealing with a lot of extra parenchyma. So unless your cancer's not letting you transect there, if it's just straddling that neck a little bit right over top of the portal vein every time,
Dr. Randy Lehman (27:04):
And then you have to transect your genum.
Dr. Cate Straub (27:08):
Yeah, so then you get to take a break from all the madness that you've been dealing with up there. It's kind of nice to go to a nice virgin part of the belly for a little bit. Hopefully you've done a lot of your ization, so you're almost all the way through that ligament of Treitz. You pull the colon up into the upper portion of the abdomen. I usually measure down to just about that first tributary. You want to make sure that wherever you transect your jejunum, that your distal jejunum has enough flexibility that it's going to easily come up and sort of recreate that C shape up in the upper part of the abdomen. So you want to get away from that part of the ligament of Treitz in that first bit of the jejunum where the mesentery is really, really thick from being tethered down there.
(27:45):
And that's usually about 20, 25 centimeters away from the ligament of Treitz, linear cutter, 75, I already opened it. And so I just use another blue load on that. And then I usually use my, I do use a lot of ligature Maryland shorthand, and I kind of take down my mesentary with that. I stay very close to the bowel. I don't want to risk getting into that first AL branch that kind of wraps around the SMB and comes down to the rest of the mesentary and then take down the retroperitoneal attachments, so the ligament of Treitz until the whole thing just wants to kind of slip up into your upper portion of the abdomen again. And then once you've kind of pulled that through, hopefully most of your specimen is almost on a pedicle of just the uncinate process coming off of the SM where it's attached to the SMA.
(28:30):
And so you start peeling your portal vein and your SMV up and kind of dissecting sort of along that uncinate process as it comes along under there. And barring any vascular involvement, there should just be a couple tributaries from the pancreas to the portal vein that you have to take. And then you want to really make sure, because your uncinate margin is one of the only margins you have really good control, not good control over, but your pancreas margins important, your bile duct margins important, and that unsent margins important. And you've probably had frozen sections telling you you're out of the woods with the other two and the uncinate is just this one that you really got to be careful of. And there's usually a really good groove if you've done a good Kocher off the SMA along the unsent and you can just sort of fire your LigaSure along there and free it up. It makes it sound easier than it is.
Dr. Randy Lehman (29:22):
Yeah. Alright. And then you send the specimen off any stitches or labels or anything, they can pretty much
Dr. Cate Straub (29:28):
Figure
Dr. Randy Lehman (29:28):
That one out?
Dr. Cate Straub (29:30):
Yeah. Well first I labeled pancreas duct bile duct and SNP process. But almost every time I go to path the next day and I gross in my specimen with them and I make sure that they're getting all that right. I'm in the path lab all the time,
Dr. Randy Lehman (29:44):
And then you bring your bowel up through and it hopefully is all free. And then thank you so much for explaining the why behind what you're doing and not just telling me exactly what you're doing. So keep that up. And then if you bring, you have to make three and anastomosis. So
Dr. Cate Straub (29:58):
Pull up your limb of jejunum, you've got your three anastomosis left to do, and you're going to start with your toughest one and go to your easiest one. The pancreas is by far the toughest anastomosis, and by the time I get to the stomach, I'm pretty relaxed. So basically I do an end side anastomosis. I put some corner stitches in held loosely just to kind of line things up. And I do a single sort of horizontal mattress suture that kind of lines up my posterior pancreatic wall with my duodenum and kind of takes some of that tension off. I boat the suture a little bit, so it does a nice big horizontal mattress. And then one of the keys that I learned from Dr. Ty is when you make your tiny little and you bring up your mucosa, it is so important that you get your mucosa of your small bowel and your mucosa of your duct to approximate.
(30:53):
And it can be very, very hard when you're taking these minuscule bites to make sure that you're getting that. So I actually pull that mucosa out of my small enterotomy and I tack it out onto the bowel in three places essentially, or four places, essentially turning it into a tiny stoma. And so that you just have really good mucosa. And I think this has really helped me from back walling or grabbing the wrong muco from the other side closing off my duct. It's just given me really good landing sites for my sutures. Then the vast majority of pancreatic anastomoses are performed with about six 4-0 PDS sutures interrupted. If it's a really big duct, it might be more, but the vast majority of 'em are about six sutures. And then I do a running silk to sort of pull the anterior border over to the jejunum and kind of take pressure off of that duct all anastomosis. You
Dr. Randy Lehman (31:50):
Said you put a four stitches to kind of approximate things. What are those
Dr. Cate Straub (31:54):
Stitches
Dr. Randy Lehman (31:55):
To?
Dr. Cate Straub (31:55):
So the four stitches, it kind of creates, like I said, this little tiny stoma around the enterotomy, it kind of pulls it out and pulls that mucosa out, so you can just see it beautifully. Most of the time when you make that tiny little enterotomy, the mucosa dives back in.
Dr. Randy Lehman (32:10):
But I thought even before you're talking
Dr. Cate Straub (32:12):
About
Dr. Randy Lehman (32:13):
Setting it up, do you put some stay stitches too?
Dr. Cate Straub (32:15):
Yeah, I put two corner stitches that just sort of hold the edges of the pancreas, sort up to the jejunum, and then those aren't tied down until the end. You just kind, they're kind of approximating it. And then I put that posterior stitch in that kind of holds the posterior wall. Does
Dr. Randy Lehman (32:31):
It sort of invaginate the pancreas into at all or
Dr. Cate Straub (32:36):
It's not really invaginated, it's just sort of bluntly right up against, and those stitches just take all tension off of the true anastomosis, which is the duct to mucosa anastomosis. How big of
Dr. Randy Lehman (32:48):
A bite do you take on the pancreas with those stitches, the stay stitches
Dr. Cate Straub (32:54):
That you place
Dr. Randy Lehman (32:54):
At
Dr. Cate Straub (32:54):
The beginning? The stay stitches. I take a superior and inferior, like a full thickness bite through them, like two
Dr. Randy Lehman (33:00):
Centimeters back
Dr. Cate Straub (33:02):
And one to two centimeters back. Yeah.
Dr. Randy Lehman (33:04):
And what kind of stitch is that? Is a PDS as well?
Dr. Cate Straub (33:07):
No, it's just a 3-0 silk. I'm old school. I use a lot of silk. I could probably switch to something fancier, but I like silk.
Dr. Randy Lehman (33:14):
And then you said six or so sutures of 4-0 PDS for your mosis, those four stitches that you sort of created, the mini stoma, do those get cut and removed as the operation going?
Dr. Cate Straub (33:28):
No, they just kind of stay in the way I kind of do it. Those are sort of offset in between the six sutures, so they're not really on top of each other. It's a lot of suture in a very small space, but they're not on top of each. All the knots are
Dr. Randy Lehman (33:41):
Going on the inside of the,
Dr. Cate Straub (33:44):
No, you don't want any knots on the, if you can on the inside of urine anastomosis, those can be kind of S for stone formation and pancreas, duct stones following a whir are really tough to deal with.
Dr. Randy Lehman (33:59):
Sure. Okay. So your knots are going on the outside of your anastomosis, then you have some 3-0 soaks to put your bowel,
Dr. Cate Straub (34:05):
The anterior back together? Yeah.
Dr. Randy Lehman (34:07):
Okay. And then anything else on that or go onto the B duct?
Dr. Cate Straub (34:11):
Nope, I like that one. Yeah, that sounded like a solid anastomosis.
Dr. Randy Lehman (34:16):
Very lowly. Great on that one. And then we got to do a bile duct anastomosis on the right lateral superior jejunum. And
Dr. Cate Straub (34:27):
That
Dr. Randy Lehman (34:27):
One. Any
Dr. Cate Straub (34:29):
Tips or tricks? Yeah, this one's pretty straightforward. You make your enterotomy and because this enterotomy is a little bit bigger, the mucosa tends to want to invaginate out, so you don't need to do those stoma ization sutures still 4-0
Dr. Randy Lehman (34:42):
PDS
Dr. Cate Straub (34:42):
Still 4-0 PDS interrupted all the way around. Start with the back wall, sort of bring your back wall in with one or two stitches and then just go around from the back coming up and I just lay them all in individually and then I tie them at the end.
Dr. Randy Lehman (34:55):
Do you tack that jejunum up to any other tissues around to take off tension in any way or?
Dr. Cate Straub (35:01):
I don't. In training, there were some people that sort of brought some falciform down or tacked it up to sort of that biliary plate, but I have not had a lot of issues with the bile duct anastomosis in that way at all. Okay. I think the prevention of leaks after Whipple is obviously such a hot topic and there's a lot of things you can do. People have looked at sort of wrapping the pancreatic anastomosis in falciform, spraying it with all sorts of glues and things like that. And very few have had long-term viability of showing that they've improved things. So my leak rates remain sort of the average, and I keep it at that.
Dr. Randy Lehman (35:43):
And then your stomach,
Dr. Cate Straub (35:47):
Your
Dr. Randy Lehman (35:47):
GJ do, so you make your GJ not with that limb?
Dr. Cate Straub (35:54):
Well, it's sort, you go back down below the transverse mesocolon colon, you measure maybe another 20 centimeters just so that it comes up easily. I usually do a retro colic. I make a little window through the mesentery, bring it up that way. You don't want to make your limb too long for a variety of reasons, but one of which is so that your GI doctors can access your pancreatic and biliary anastomosis if necessary. And then it's just a, I do a hand zone, two layer anastomosis silks on the outside and a running double arm Vicryl on the inside.
Dr. Randy Lehman (36:33):
Beautiful. And then
Dr. Cate Straub (36:35):
What you do? I left hand sew bowel anastomosis I think are awesome. I love doing hand stone bowel anastomosis.
Dr. Randy Lehman (36:41):
I even just at least close my common enterotomy hand sew because I can't.
Dr. Cate Straub (36:44):
I do too. Even if I do a staple common channel, I hand sew that Romy at the end.
Dr. Randy Lehman (36:50):
So when you hand, so that, what stitches do you use
Dr. Cate Straub (36:56):
The common enterotomy after a routine stapled anastomosis? Yeah. It's usually sometimes, depending on how big it is, you can just take a 3-0 vicryl starting at the crotch up and then you can almost turn it back around and sort do a running Lembert back down to where you started from. But that's kind taking practices that I learned robotically and applying them to open surgery's. But otherwise it's just, yeah, it's a fun trick. But otherwise it's a running through Vicryl and then lumbered individual through Vicryl. I'm a two layer person. But you don't
Dr. Randy Lehman (37:30):
Put 3-0 silks on that?
Dr. Cate Straub (37:32):
Well, usually because I'm doing it all with the same Vicryl, there's some reasons that, I mean, I think for me, the Whipples epitome of it ain't broke, don't fix it. So I just haven't really changed that in so long that I'm still using some pretty old school sutures and techniques on it. Yeah,
Dr. Randy Lehman (37:50):
A hundred percent. Very good. Anything else? So then as you're coming out, do you do anything with the omentum over the top or anything?
Dr. Cate Straub (37:57):
No. No. I used to routinely float nasojejunal tubes down so that they had a little feeding access help, but honestly, I've been getting patients eating faster and faster. And back in my training, nobody ate for five or six days after a Whipple. And hopefully at five days you're going home after my Whipple. So I just start feeding them mentally a lot faster.
Dr. Randy Lehman (38:18):
How often, when do you let 'em have clears?
Dr. Cate Straub (38:20):
Next day I probably don't even need to leave the NG tube in that I do universally pulling it out the next morning and starring the Mont clears.
Dr. Randy Lehman (38:29):
And what drains do you put in and where?
Dr. Cate Straub (38:31):
I do universally put one drain just running sort of over top of both the biliary and pancreatic anastomosis. I am always fiddling with my practice as far as routine drain amylase is, I think that's one part of a rural practice was convincing our lab to check drain amylase. They said they weren't validated for it and it took a long time to get them capable of checking drain amylase or the things you don't think about what's going to be the one big holdup in your pancreas practice, your lab checking drain amylase. They kept sending them all out to mayo and they were taking eight days to come back.
Dr. Randy Lehman (39:06):
Wow. Wow.
Dr. Cate Straub (39:09):
So yeah, at this point I check a drain amylase usually on day three. And then if there's any concerns on day five before I pull it out before they go home.
Dr. Randy Lehman (39:19):
And just for the sake of completion, how do you close your fascia and your skin?
Dr. Cate Straub (39:27):
I use a running OPDS usually on a CT one needle times two, starting from above and below and closing in the middle, irrigate the wound and close with staples. Pretty same old, same old.
Dr. Randy Lehman (39:39):
Beautiful. Alright. Wow.
Dr. Cate Straub (39:42):
Wow. You really dove into it.
Dr. Randy Lehman (39:44):
I mean I like it and I cannot believe you went through all of that with me.
Dr. Cate Straub (39:51):
I can't believe it. I felt like I just dictated my op note,
Dr. Randy Lehman (39:55):
But thank you. No problem. For me, it was fun. We only have just two quick hit questions because you already did the other one. Do you have a financial tip for our listener?
Dr. Cate Straub (40:08):
Yeah, I thought about this a bit when you said you were going to ask about it. And I have to admit, of all the things that I try to pull off in my practice, understanding the finances of medicine is probably not my real house. But what I would say is as a rural surgeon, I think any of your listeners who are in rural practices know that your hospital will continually try to get you to do more, whether it be to take on more clinical work or more administrative work. And if you're not careful, you'll be giving a lot of yourself for free. And so my financial tip is really just that as you are continually asked to take on more roles in your hospital, that you understand your worth and whether or not that worth is money or that worth is time to not be afraid to ask for what you are worth for that it was a hard model to come up with a means of being an acute care trauma surgeon who gets paid per shift and be essentially salaried for a certain number of shifts, but continue to want to do Whipples on the side.
(41:11):
And how do you figure out how to get paid for that? There was no good way to do an RVU cutout for that. So I was asked to calculate an hourly rate for all pancreas work, including clinic time, rounding time, and surgery time. And that was more challenging than I thought. This only happened two years ago when I switched to a CS surgery and how to calculate your worth, what should you be paid by the hour for pancreas cancer work was really challenging to figure out it
Dr. Randy Lehman (41:43):
Should have four digits. That's my opinion. It
Dr. Cate Straub (41:47):
Doesn't, but I appreciate that. But yeah, so part of it is in rural surgery you will be handed a lot of opportunities to improve your hospital to improve care for your patients. And each of these is going to be incredibly demanding of your time. So figure out what you're worth and what to ask for so that you don't burn out on your job.
Dr. Randy Lehman (42:12):
Yeah, I love it and I love that you're saying that it's not always money. I mean I do real estate investing too, and I do obviously surgery and both of 'em, there's a little overlap in this. It's not always the price, it's more about the terms. So
Dr. Cate Straub (42:32):
Very good. Yeah, absolutely.
Dr. Randy Lehman (42:34):
Alright, and then lastly is resources. For the busy rural surgeon, do you have any resource that you just think every rural surgeon should know about?
Dr. Cate Straub (42:42):
Well actually, I mean my resource I think is far more generic. Obviously I could point you at the videos on the SAGE'S website and things like that. I'm sure people on your program have talked about things like that before. I think your greatest resource as a rural surgeon is your referring the surgeons that you are going to refer to, whether that be me or the tertiary center. I think it's very easy as a rural surgeon to feel like every time you have to call one of those surgeons that they're going to think you're dumping on them and that's going to breed this lack of communication where all you're ever calling for is when you have to get rid of a patient. And one of my passions dealing with national organizations and the Rural Surgery Advisory Council through the A CS is to kind of create a world where rural surgeons feel comfortable talking to other surgeons and vice versa. And just giving advice and seeing how we can keep patients in closer to home in their home hospital system and that not everything that gets a little complicated has to be sent out. And I think if we can only communicate with each other better, that doesn't have to happen as much. How can we do that? We all know, sorry.
Dr. Randy Lehman (43:55):
How can we do that? How can we develop those relationships? What's the best,
Dr. Cate Straub (43:58):
Most natural way? I think from a more national standpoint, I think just having sort of guidelines of who your referral base, who you refer to, who the touch points are there, and making sure that those numbers are readily shared between each other. And then there's the possibility even dealing with better telehealth between things. So you could be this, you could call me on a telehealth system when I'm on call and be able to say, I've got this patient. I'm not entirely sure if I need to send them or not. This might just be a routine post-op ileus, it might be something more. And we could talk about what your resources are, what you can do when to ship, when not to before it becomes just a, I need to get rid of this patient.
Dr. Randy Lehman (44:43):
If I was going to pick you up, you're not going to do pancreas anymore.
Dr. Cate Straub (44:48):
You're
Dr. Randy Lehman (44:49):
Going to do
Dr. Cate Straub (44:50):
Sounds lovely. Honestly,
Dr. Randy Lehman (44:51):
You're going to do critical access medicine in Mississippi and I drop you at a critical access hospital. How would you develop those relationships with who is the most important and how would you go about meeting those people?
Dr. Cate Straub (45:09):
I mean, is it so hard just to call people when you're not needing to call them about a patient? I think I would look at the hospital. That tends to be where my team, where my hospitalist tends to send all of their referrals. I would call whoever's the general surgeon there. And I'm assuming there would be more than one maybe offer to get together for dinner and kind of chat about what I'm capable of doing and what they do and how we can help each other. I think when you have a chance to develop those relationships when it's not being driven by a specific sick patient, it's better to kind of chat about that and then to also just know that to take it a step further, I think the first time I reached out to the University of Washington and Virginia Mason, I thought again that they were just going to think, who's this podunk surgeon trying to do all this stuff out there?
(45:58):
And what I've learned is they're just so grateful to have people trying to do things and they're not there to steal my patients. They're there to keep my patients near me whenever humanly possible. And developing those relationships early and often and not when it's acute is the best thing to do. So yeah, if I was in your critical access hospital in Mississippi, I would ask, where do all my patients go? I would call the surgery team that works there and I would develop those relationships. Maybe that means developing a relationship with the GI team, with the IR team. I don't know.
Dr. Randy Lehman (46:34):
Yeah, it's a lot. It ends up being, first off the answer that you gave, which is that your best, best resources, your cell phone is actually the most common on this show. Yeah, and it is the right, I mean there's no right answer, obviously it's right answer board's answer, but it is, I would say if I had one resource, it would be the contact list too. But fortunately it's real world. So we don't just have one resource. But two more follow up questions and then get you out of here. So what would be the essential surgical subspecialties that you would call ahead of time to know, for example, sson, HPB, what else? General
Dr. Cate Straub (47:20):
Surgery. So who would I have in my, for lack of a modern turn, my Rolodex for these people to call? I would say the ones I would want a trauma surgeon,
Dr. Randy Lehman (47:31):
The person you're talking to right now is a resident who's going to go find themselves in that situation. And they don't even know that what you're just saying. And so for me, the things that I send out, it's like if you find yourself with a bile duct injury, okay, who are you going to call? And the hernias that you don't want to do, but they still need their hernia fixed and they're going to need to be done at maybe a university setting or whatever. Who's the hernia guy at that place? Those would be probably those two. And then S onc would be the three most common surgery referrals that I send out. Is there anything else Im missing? I would say
Dr. Cate Straub (48:05):
The things, yeah, I would say in my practice where the things that I need to send out the most is complex colorectal stuff like the low rectal tumors, the complex IBD or the bad anal fistula patients where it's like trans enteric and they're going to do lift procedures and stuff too. The HPV anal wart patient that's going to need the surveillance with the special anoscopy and things like that. I find that I'm sending a lot of people out for colorectal stuff.
Dr. Randy Lehman (48:36):
And
Dr. Cate Straub (48:37):
How about for that is more elective? I would say emergently. Honestly, it's knowing your trauma surgeons. I mean, everything happens so fast with trauma surgery that you want to have good relationships with those people so that when you call them in a panic, they know that you're capable. They know what you can do there and what you can't there and why you're sending them somebody. I recently shipped a through and through liver injury, I told you I have a lot of gunshot wounds, but having that trauma surgeon I sent him to on speed dial, being able to not only talk to him in real time about the patient I'm sending him and not just going through a transfer center, but also being able to coordinate. Now he has a bio leak and a drain and he's going to come back to my community and he's not just being dumped there and told to find a general surgeon because I can communicate with that person. I think HPV for the bile duct injuries. Those are just so devastating. Yeah, those are probably the really big ones. I mean
Dr. Randy Lehman (49:34):
Forge,
Dr. Cate Straub (49:35):
Sorry,
Dr. Randy Lehman (49:36):
Forge.
Dr. Cate Straub (49:39):
Forge get less. So for here with my partners and I think major hernia I think I've come to appreciate is such a specialized field that you really have to know are you capable of doing tars or not or do you even want to take those patients on and whatnot? Something
Dr. Randy Lehman (50:01):
You might find interesting in six years, I don't think that I have once called a trauma surgeon.
Dr. Cate Straub (50:08):
Oh really?
Dr. Randy Lehman (50:09):
I don't see any trauma because they don't show up at our hospitals.
Dr. Cate Straub (50:13):
Okay.
Dr. Randy Lehman (50:14):
Because if they're really that bad, they ship from the field
Dr. Cate Straub (50:18):
From the scene. Yeah.
Dr. Randy Lehman (50:20):
None of the places I matter are leveled trauma centers. They're not even level three. So there you go. But I say that just to show you the difference of what a rural practice, you have a rural practice 100%. So do I. But they're quite different.
Dr. Cate Straub (50:37):
They're very, very different. And I think, yeah, it's important we're a level three, but at the same time we're hours from everywhere else. Yeah. Everything in the region's
Dr. Randy Lehman (50:46):
Going to
Dr. Cate Straub (50:46):
Come there, everything dumps down and then we figure it out and have to send a lot away. I mean, we virtually never have neurosurgery. We only have one head neurosurgeon and it's only every other week just by daylight hours during the week. So anything else we can, I can't remember the last time you did a cranny. We don't have ability to bolt or do dool, so they all go.
Dr. Randy Lehman (51:05):
The other thing I would say is your state Indiana or not state, your state American college surgeon's chapter.
(51:13):
If you go there, you showed up first off the person that's an academic surgeon that sees the rural surgeon at that meeting, it says something about you already that you showed up, you already have clout. You see how the stupid level of questions that I ask you about this specific topic, which I guess I could have prepared more, but that's me training at A HPB referral institution. And I got after it in residency and worked hard and did great on my apps sites and everything and boards and whatnot. And not everybody has the opportunity to train at that level of place, but all you can do is take yourself from the place you are now to where you're going to go and operating inside your sphere of competence, keeping your Rolodex. Thank you for those tips. I just think that's great to elevate the quality of rural surgery that's being delivered everywhere, which is going to help the whole country and
Dr. Cate Straub (52:15):
Reputation
Dr. Randy Lehman (52:16):
Wise and talk about that trust factor and all that.
Dr. Cate Straub (52:19):
Yeah, absolutely. Absolutely.
Dr. Randy Lehman (52:21):
So thank you for joining me on the show, Kate. And I did want to say, did you want to say any kind of plug about the program, what you guys have for the Rural Surgery Med Student program? Yeah,
Dr. Cate Straub (52:33):
I mean obviously I'm affiliated mostly with the University of Washington and Washington State University, both of which who have different sort of rural tracks. And I mostly have students who actually aren't from Washington currently. My students from Montana, I have students from Alaska and all surrounding states. It's part of the Whammy program or the Washington, Wyoming, Alaska, Montana and Idaho program that all tend to rotate through here. And as far as the surgeons out there, the residents out there that are looking for future jobs, I got to tell you our, we are almost never hiring because we've all been here our entire careers and we all hope to retire here. And I mean it is wonderful. I mean it is such a rarity to practice in a place where everybody starts their job there and their goal goal is to end their career there and it feels really, really, really good. I mean, one of my partners grew up in this town. His dad was a radiologist I worked with, all of his brothers are doctors and are coming back to this town. We have a lot of longevity in our program. That's
Dr. Randy Lehman (53:42):
So cool. Well, I am so glad that I got introduced to you and that you took the time to come and have this conversation with me. I look forward to seeing you through the a CS and wish you the best with everything.
Dr. Cate Straub (53:54):
Come to our session on and speak up about rural transfer dilemmas.
Dr. Randy Lehman (54:00):
Sounds good. Alright, we'll see you in September then.
Dr. Cate Straub (54:04):
Yeah, absolutely.
Dr. Randy Lehman (54:05):
I'll take us out. Thank you to the listener as well for being here. This has been the Rural American surgeon and we will see on the next episode of the show.
