EPISODE 54
Why Confidence & Judgment Matter More Than Fellowships in Rural Surgery | Dr. Amy Vertrees Pt. 1
Episode Transcript
Dr. Randy Lehman (00:00):
Hello, listener and welcome back to the Rural American Surgeon Podcast. Today's guest is phenomenal
and she's a military surgeon. I know many of you are military as well. She has quite a story to tell mainly
about autonomy, how rural practice can enable this. And then we went into an excellent how I do it. So
this is going to be the first of a two-part series with Dr. Amy Vertrees from the Boss Business of Surgery
Series, as she's known in a CS circles and other places. So without further ado, let's get into the show.
Welcome back, listener to the Rural American Surgeon Podcast. I'm your host, Dr. Randy Lehman, and
I'm very honored to have with me today Dr. Amy Vertrees. Thank you for coming on the show. Dr.
Vertrees,
Dr. Amy Vertrees (00:44):
Thank you so much for having me. Such an honor.
Dr. Randy Lehman (00:47):
Yeah. So let's lead into a little background about you. If you could tell us your background training and
then what your past practices and current practices look like.
Dr. Amy Vertrees (00:55):
Sure. So I went to the military medical school, Uniformed Services University of the Health Sciences. A
lot of people haven't heard of it. It's the only military medical school we have. It's in Bethesda, Maryland,
and you become a commissioned officer in the military. So I commissioned into the army in 2000 and
went to military medical school from 2000 2004, I was in the DC area. I ended up doing general surgery
residency at Walter Reed. I was asked to stay on of staff and deploy three times as an army surgeon. And
after I finished my residency and my payback for the military, I got an employed job for three years. And
then after three years when my contract was up, I started a private practice. So I'm currently in private
practice that was initially meant to be a cute little solo practice and now I've got five surgeons, two nurse
practitioners, and we cover three hospitals.
Dr. Randy Lehman (01:48):
And it's very interesting. We have some similarities in that regard because I went to hang up my shingle.
That was my dream to go back to my hometown and just be independent solo practice, general surgeon.
But then I've identified these needs in rural surgery at the critical access hospital sort of in a regional area.
And it's just been a kind of development of a deeper understanding of what the needs are of each place.
And I feel like you guys are kind of doing the same thing. And so your practice is growing in a similar
way. Maybe we can dig into some of the ways things that you've learned about that. Maybe I'll just ask
one question. What's been the hardest part of doing what you've done
Dr. Amy Vertrees (02:34):
Specifically a private practice? It's interesting because it unravels over time. So it's funny because there
was this neurosurgeon that's sharing space with us now and he's early in the private practice thing. And
I'm seeing some of the struggles I had early on that I don't have anymore. So when you first start a private
practice, the first thing is overwhelm. It's where on earth do I start, what am I supposed to do? And there's
so much that we don't know because there's so much of the business of surgery that we're just not taught.
So the first is overwhelm. How do I do all the things and not make mistakes? And then it's how do I grow
this practice? How do I work the math problem that is making sure my incomes are more than my
expenses and make sure my tax burden isn't too high? And then it's just the same things that all of us have
is how do I manage my time and how do I work and ensure that the patients are well taken care of and
that my time is managed well.
(03:27):
But with private practice, all the things that frustrate you as an employed surgeon are now your job. So all
the administrative things that bother you and the people holding you accountable for things and also the
structure that now becomes your job, which is great when you feel like you want to do it, but it can be a
little overwhelming of trying to find out how do you influence the people around you? How do you pick
the right people? How do you make sure that everyone does what they're supposed to do? So you have to
really understand other people's jobs as well and how do you inspire them to be great at their job and want
to stay. So those are I think probably the biggest challenges.
Dr. Randy Lehman (04:04):
Yeah, why bother? I mean, what's been the best part about it? If somebody else was considering you were
going to say, yeah, you should. This would be the number one reason.
Dr. Amy Vertrees (04:17):
Employed surgery is not the worst thing in the world. If you are at a place where it's managed well and
there's always going to be some headaches, it's not a terrible thing to be at because the stability and you
don't have to worry about a lot of things. And my particular case, at the end of my employed contract, I
thought it was about the money. So I negotiated a huge raise and then three months later it was clear as a
bell I would be complaining of the same things for the next 15 years and nothing was going to change. So
for me, I couldn't make any changes and I couldn't evolve the clinic. To give you one example, this was a
mind blowing day. We don't have a voicemail on our phone. When I was in the clinic and I said, why
don't we have a voicemail?
(05:03):
It's like if someone needs to leave a message and they said, I don't want to give the impression that we're
going to be answering it. So what is run in a way of, I mean, what are we doing here? I just felt like the
clinic represented me and I wanted to run the clinic in a certain way. I wanted my patients to have a
certain kind of experience and I was running into the constraints of the fact that patients couldn't leave a
message and they were given slots that I couldn't necessarily adjust and the people support staff weren't
really helping me. Now I discovered over time that some of it was things that I could change. So I think
now with the skills that I've learned over time, I probably could influence a job a little bit more than I
could have before. But there's certainly some constraints of just like this is the way it is. And if you're
under a difficult manager or a difficult administrative hierarchy, then you may be really frustrated in your
job. And I think that's really where a lot of people get dissatisfied is the people that they encounter.
Dr. Randy Lehman (06:08):
Got it. So basically the control and the autonomy and your microenvironment and all those things, I tend
to agree with those things. So thanks for bringing it out. So now that you're practicing what's the size, the
next question on the show is why is rural surgery special to you? But I want to know what the size is of
the three places that you guys are practicing now and are you personally privileged at all three sites?
Dr. Amy Vertrees (06:33):
Yes, I'm privileged at all three sites. And how it's evolved was when I left the military, we had the
privilege of being trained to deploy and do all the things. So for example, my first deployment I was
doing thoracotomies, neck explorations, complex abdominal surgery, including dealing with the pancreas,
the kidney. I managed a bladder injury that was complex. So we were trained to manage a lot of things
and I really wanted to have a broad-based practice. So luckily we had a rotation that really spoke to me,
and it was a community hospital initially, so to have the full breadth of things that a general surgeon
could do, so maybe not as many specialists and do a lot of things to have a very varied practice but still
have some support. That was initially the hospital that I chose after leaving the military was a community
hospital's 250 bed non-for-profit hospital and really enjoyed it.
(07:31):
I really enjoyed the OR and the people. It was a perfect size, I thought initially of being able to do some
big things, have some support. So it was a good balance. Now over time, over the last year, year and a
half, we started realizing that there's two hospitals nearby. Now these I think are billed as 90 beds, but
that includes some of your swing beds, your rehab beds, things like that. Practically one of them has three
ORs, so I think the other one has five. So smaller hospital, they both have very small ICUs that don't quite
have the same level of ICU of other places. So as far as rural surgery goes, I think they're a little bit larger
now. I think the biggest challenge with these rural surgery hospitals is how do you fit the right surgeon at
this place? So you have the one person who could do it all and it could fulfill like a full-time surgeon,
probably a little bit more, but they would not necessarily have coverage.
(08:28):
And so what we found that we could offer, which allowed our practice to expand is to say we have one
full-time surgeon for you, but we now have a backup of multiple surgeons behind us that can help
circulate the call to make sure your call is always covered, to make sure that we can have some of these
younger surgeons who may not be as experienced. So we can do more broad things with confidence, with
good quality and also the other side. So I think in these hospitals, if you get one person, you're going to
get the young person who maybe can get in over their head and that can actually end your career if you're
not careful older person who's on their way to retirement. So I think some of these communities run the
risk of having that particular kind of surgeon. What we wanted was to have a surgeon there that had a bit
of a passion for rural surgery, which we have in both of those places. Now the other two hospitals and I
provide the support as the senior surgeon. So they book days of more complex things to where I can come
see them and all of them are within driving distance of my hospital. So I'm always willing to come into
some of the more complex cases. So essentially what we have is a hybrid of younger surgeons and a
senior surgeon who are managing all the problems and we call it the zone defense.
Dr. Randy Lehman (09:47):
Yeah, no, I love that. And it actually is take a moment to talk about what I have going on in Indiana
because I wasn't four and I'm in three hospitals, I'm kind of trying to get the alignment for what I'm trying
to do. And I have some very interesting developments where we're probably going to add more of a hub
hospital and that'll be the bigger place that has the real ICU has inpatient cardiology, dialysis, things like
that that you can, because I'm running into issues at all three hospitals that you're talking about. Do they
all have 24/7 call coverage?
Dr. Amy Vertrees (10:25):
24/7 call.
Dr. Randy Lehman (10:27):
Okay. Because all three hospitals that I have do not. So these hospitals are all critical access 25 beds or
less, but their real average daily census might be more like five to 10 in the whole hospital. One place has
four ORs, but I mean we never use more than one and they only have anesthesia on select days and
things. So it's a very different, and even the hub model for me is probably the size of one of your smaller
hospitals
Dr. Amy Vertrees (10:58):
Beds and staffing. Completely different number.
Dr. Randy Lehman (11:01):
Correct. Yeah, that's true. So anyway, I guess what I'm doing now is potentially building this hub model
and even with the three places I currently can't meet the demand, and I've hired a surgeon this year, my
first surgeon hire, that was my big goal for 2025. I've been reviewing my goals because it's beginning of
the year and I did it. I can't believe it. And I look back and think about all the different surgeons that I
talked to and I had on my goal list for the next month get contracts signed with X, Y, Z surgeon several
times that are surgeons that do not work for me. And then the right person came at the right time and it
was obvious and we moved forward. I also hired another a PP for wound care and yeah, it's a growing
group, but I'm going to plug out there right now for myself that I need more surgeons and I don't need
them right this second, but I am really very likely going to need probably two.
(12:07):
And I have myself and now I'm five and a half years out. And then I hired an experienced surgeon who
has maybe 15 or 20 years of experience, very good, very good mentor, and I would look for someone with
experience, but I would also look for somebody that was out of training and the timeline of maybe a
couple years I signed my contract. It's actually in second year, December my second year for three and a
half years in advance. And I don't think a lot of people look that far in advance, but if that's something
that you're interested in, then I'll tell you go to the rural american surgeon.com and just submit your
information there on the contact page. And that email then comes to me and I would love to hear from
you and talk, and I would love for you to come visit me in Indiana. And even if it doesn't work out, I'd be
happy to advise you about places that may be right for you and just let you have my network and my
advice, especially if it's somebody that is another colleague, another general surgeon that's looking for the
right thing for them. So sorry to stop and make a plug, but that's what I have going on,
Dr. Amy Vertrees (13:25):
How you get jobs. I didn't advertise any of my jobs except for in networks that I had.
Dr. Randy Lehman (13:30):
Yes, perfect. And you have quite the network, and we'll talk about that in a minute. So that's a teaser. But
before we do that, so now we understand what basically rural surgery means to you, what kind of hospital
you're in. So why is it special rural surgery?
Dr. Amy Vertrees (13:47):
It still stretches all the things that you think you're capable of doing. So I think the main problem that we
have with training these days is this idea that you have to be fellowship trained to do certain things and
that you can't do these things. And the more you tell people that they're going to actually follow that like,
oh, I can't do rectal surgery because I'm not a colorectal surgeon. I can't do exactly. So I mean it's all
anatomy exposure, understanding the risks, the benefits and the tips and tricks. So as a surgeon, we can do
more things. So I like the idea that there are areas that both allow us to do that but actually really need us
to do that. So it was interesting. I talked to one of the CEOs of one of the hospitals here, and he had this
idea that this hospital was going to grow into basically a mini Knoxville, a mini thing.
(14:44):
He's like, we're going to have colorectal surgeons and cardiothoracic and this and that. And I said, you're
really missing the point of what this hospital has to offer, which is broad-based easier access than going to
some of these places up north where there's difficulty. But to build something of that size to keep the
people satisfied, everyone really needs a certain amount of volume to be able to do these things. And so
it's just interesting how there's different personalities for hospitals. So I guess my point is is that we have
our own desires, what we think we are capable of doing and want to do, and there are different
personalities for hospitals out there. And so finding the right personality that fits what you want to do and
the personality of the hospital that doesn't have an identity crisis is I think really where people will be
more successful.
Dr. Randy Lehman (15:34):
I was listening to something recently just what you're talking about, which is it was a hospital
administrator talking about success that they had had in their area. And basically what they were saying is
don't try to be the big academic center or the big tertiary center hospital. They lose. Their identity is
perfect. So figure out what is needed in your community and do that very well. The 80 20 rule or
whatever, the 80 90% of the things, capture those and do them very well. Meet people at their point of
need. Understand that if you build all of these other service lines that are going to end up being low
volume, it's going to drag your revenue down. So find the high volume things where you can meet the
most need for the most people and then you're going to have a huge platform, an actually profitable
platform underneath you. Let's move into the next part of the show. That's called the how I do it, and
we're talking about volume and whatnot. We're going to talk about laparoscopic and robotic inguinal
hernia today. So preparing for this, there's 600,000 inguinal hernia repairs done in the United States per
year.
(16:51):
Do you have a number in your head of how many practicing general surgeons are in the United States?
Dr. Amy Vertrees (16:58):
I feel like I've heard that number before, but I'm not 100% sure.
Dr. Randy Lehman (17:01):
So I looked it up, but I'm coming up with differing numbers.
Dr. Amy Vertrees (17:05):
I knew there's 150 general surgeons in the army, but that doesn't help you much.
Dr. Randy Lehman (17:09):
Well, if we knew how many inguinal hernias they were doing, but there's 34,000 certified by ABS. So
then the question is how many of those are practicing as general surgeons or are they peeling off into
other subspecialties? And there's other surgeons that are maybe not certified by ABS, also maybe still
practicing as general surgeons. So I came up with between 17 and 40,000 total general surgeons in the
United States when I was looking, and I kind of feel like it's a number less than 34 that are actually
practicing general surgeons, but it's not going to be less than 17. So shall we make an assumption that
there's 20,000 practicing general surgeons?
Dr. Amy Vertrees (17:57):
It seems reasonable. I think the only other number I know of is there's 90,000 members of the American
College of Surgeons, but that's lots of specialties
Dr. Randy Lehman (18:04):
Possible. Yeah, exactly. So say there's 600,000 inguinal hernias and 20,000 surgeons doing them, that
would be 30 per year. And how does that number strike you? Because at first blush, it seems kind of low
to me, but then I start thinking about, well, I say I do inguinal hernias every week, but do I really? What
do you think?
Dr. Amy Vertrees (18:33):
Well, I can tell you I keep track of my case log and the number one case which has been published for
most general surgeons. Number one case is lap chole or robotic or whatever, cholecystectomy. So I do
probably about 40 hernias a year, inguinal
Dr. Randy Lehman (18:48):
Hernias,
Dr. Amy Vertrees (18:48):
Gallbladders a year.
Dr. Randy Lehman (18:50):
Are you talking about inguinal or lingo and ventral together?
Dr. Amy Vertrees (18:52):
That would be inguinal and ventral together.
Dr. Randy Lehman (18:55):
If you do a bilateral, does that count as two or one?
Dr. Amy Vertrees (18:58):
I usually count 'em as one. I think you could probably argue it's two, but oh, you definitely have
Dr. Randy Lehman (19:03):
Twice as much recurrence risk.
Dr. Amy Vertrees (19:06):
Oh yeah, yeah. I mean that has always been a challenge. Same is true for mastectomies. Do you count that
as one or two? So I usually just keep it simple. When I keep my case log, I just write the patient name,
what their case was, and I just call it whatever that is.
Dr. Randy Lehman (19:21):
I run into the same issues myself. So we're kind of in a range. Maybe there's like 30 inguinal hernias that
might be over the average. Maybe there's actually 25,000 general surgeons or whatever. And it kind of
jives with what you're doing. So you're kind of middle numbers because you peel out the eventual hernias
and then you're left with your inguinal and maybe that counts bilateral or not, but it gives you an idea. It's
not like hundreds and hundreds necessarily. Now, I trained with some people that were really training on
inguinal hernia repair in the cutting edge of that whole kind of period of time, and several of them had
done over 1000 tep inguinal hernia repairs. My guess is they're counting both sides, but then that's over a
couple decades to generate that. So it's still kind of in a heavy referral center where somebody's like the
expert on that, still only maybe doing one or two a week. So now we have the first part out of the way,
which is the demographics or whatever you call it, incidents and prevalence. I want to talk about exactly
how you do it. So how do you decide? Do you do open inguinal hernias as well, I assume?
Dr. Amy Vertrees (20:41):
Yeah, I kind of straddle the whole open to laparoscopic to robotics. So I've done all three and I feel
comfortable with all three.
Dr. Randy Lehman (20:50):
And in the past year, have you done all three?
Dr. Amy Vertrees (20:54):
The past year, I actually haven't done any open inguinal. Those I tend to be, if the reason why is I think
that the laparoscopic robotic repair covers the femoral space, and I've found so many occult femoral
hernias and things like that that I prefer a minimally invasive approach just for coverage of that area and
also for postoperative pain and decreasing the risk of activity limitations afterwards. So I don't think the
open inguinal hernia repair is that bad of a case, but I feel like it's not as necessary majority of the time I
have done it in the emergency setting. I did one probably maybe two, three years ago where ended up
having a sigmoid colon perforation within an inguinal area and ended up doing that open, and I used a
biologic mesh rather than a wide pore. I think these days you could probably use a wide pour mesh. And
so I usually do those. It's nice to have that skillset. It's nice to have the ability to do it, but it's not my
preferred repair.
Dr. Randy Lehman (21:58):
Yeah, sure. And you're basically of the camp then that has, which there's camps of people that says pick
the one that you kind of stick with it and then minimally invasive on all of 'em is appropriate. Of course,
if you're answering a textbook question for your boards, I would say that the time where laparoscopic
repair would be strongly preferred would be two scenarios. One would be if you have a bilateral inguinal
hernia, and number two would be if you have a recurrence after an open repair. Would you agree?
Generally that's
Dr. Amy Vertrees (22:29):
And third would be female because the higher risk of femoral.
Dr. Randy Lehman (22:33):
Yeah. And now that's actually on guidelines, which has happened even since I came out of residency.
And lemme tell you about a quick case that I did where I think that you need to take everything with a
grain of salt, and this is a exposing my failure shortly after those actual guidelines were released that say
laparoscopic is preferred for a female. I had a patient, a neighbor lives like two, three miles from me in
my small town. When I say two, three miles from me, I'm talking the house I grew up in where I've
moved back to where I'm raising my highland cows and I'm not going anywhere. I'm not a transient
surgeon from somewhere and I've got five years to burn left. It really that kind of practice, your
complications I think bother you. People talk about surgeon graveyard and stuff like that no matter who it
is just because they're another human being.
(23:33):
But the other thing about rural practice is you're going to see these people in the store and at the county
fair and it matters. So anyway, this wonderful lady, she came in shortly after and specifically to find me
specifically knew me and she had a little marble inguinal hernia. Reducible pops right in and out is about,
the marble is probably about two and a half centimeters. She's skinny, she's healthy. She had a previous,
maybe 10 years prior, Nissen gone wrong and had a duodenal perforation afterwards and had to be taken
back to the operating room and had a laparotomy and got it repaired and now she's back and everything.
So here she is, thin, healthy, tiny little thing. The guidelines had just come out almost a stem to stern
laparotomy. What do you do
Dr. Amy Vertrees (24:51):
In that particular case? I would still try a minimally invasive approach, whether laparoscopic or robotic.
Either way, probably the challenge is going to be entering the giving ports in and lysis of adhesions. So in
that particular case, being a female, I would probably still try to do that minimally invasive, just I'd
probably book it for a longer time because I imagine license adhesions may be a challenge. And I think
there've been lots of things like what are the contraindications that maybe not be contraindications? So a
big X slap incision may be one of them. Other things we think about but to be aware of are things like
prostate surgery and things like that, things to be aware of. So I don't think there's huge contraindications
for minimally invasive approach, but in that particular case, I think open probably would've been fine too.
If her main complaint is a hernia that you're staring in the face, that's helpful. But I think it does
potentially put her at risk for femoral hernia. But of course that's not the majority of hernias. It's going to
be inguinal still.
Dr. Randy Lehman (25:53):
Yeah, I mean clearly it's so obvious it's not ephemeral because of where it's at on the exam. I mean, you
could be duped, but you're not going to be in this situation. It's up on the abdominal wall. So anyway, I
think it's a relative contraindication to do surgery, but it's relative and you have to make your call. And I
think that's the same decision that I made, but if I had it to do over again, I wouldn't. And another
question, what if you got in and it was just like crazy dense adhesions everywhere? Would you ever, I
mean, I have not really converted. I've converted some types of laparoscopic surgery to open, but I
haven't converted very many hernia operations to open. Usually I can get it done, but what level of
density of adhesions would make you convert to an opening inguinal hernia repair after you placed your
first port?
Dr. Amy Vertrees (26:49):
I think that's a good question. I think most of the time, I mean, I would probably just do it and cry about
it, but that's about it.
Dr. Randy Lehman (26:58):
So that's what I did. And I completed the inguinal hernia repair and I don't remember how many days,
maybe five or six days later, she came back with a delayed enterotomy
(27:13):
Just belly full of succus and super sick and fever and white count through the roof, and then presented to a
critical access hospital where I didn't have a call team and I didn't have an ICU and wasn't the place where
I had actually performed that outpatient operation anyway. And so I talked to her about, well, we can
transfer you over to this other critical access hospital where I do have a call team and I could take you
back and wash you out and fix the problem and potentially remove your mesh. But the reality is now
you're sick enough and you're septic that you have a very bad problem. And so this is the big challenge
for me right now where I'm at. You're out here, you're doing the best you can, and then something like
this happens. I ended up transferring her to another hospital where another surgeon managed her
complication, which is the hard part for me right now and why I'm looking more into the hub and spoke
model and finding myself at another place where I can at least handle at least my own complications on a
regular basis.
(28:25):
Because even though I have these two critical access hospitals, one has 24 7 general surgery, when I take
a patient over there, they're always like, this is a lateral move. This is not an up. And I'm like, no, it is
because they have a call team and we don't have it at this hospital. But then the CRNAs at the other
hospital are like, we're not on call for this other hospital. We're on call for our hospital. So then I was
instructing patients, if you have a complication, go to this ER because that's the only, they'll take care of
you out of the er, but they don't want to transfer. And then the anesthesiologist trying to block halfway
through, it's just complicated mess. So anyway, the patient goes and gets a washout and the laparoscopic
mesh removed and then I think might've had a temporary closure and then comes back and gets closed,
and then later gets repaired by an open technique. That's just the shambles, but it can happen. So I don't
know what kind of risk I put myself in to vulnerably put myself out here on a show like this. I'm not really
too worried about it.
(29:34):
First off, I don't think she's going to sue me, and if she does, I feel terrible about it. And everything that I
said is fine if it's discovered and put on the stand, that's exactly how it happened.
Dr. Amy Vertrees (29:47):
I have a rule when it comes to that stuff like that, when it comes to a complication or really honestly
anything, there is no role in going back in time and making yourself wrong because you made the best
decision you had with the information that you were given. So to go back in time instead of should have
done a different operation, that's not necessarily true. It's entirely possible that you could have fixed the
inguinal she presented with a perforation from her femoral hernia just as likely. So we just don't exactly
know. But going back in time, I always tell people, the only purpose in going back in time and going to
the future is to go and give yourself some information and make a decision today. So right now, you can't
change the decisions that you made and you didn't make wrong decisions. It's just what happened after the
decision you make didn't make the decision wrong.
Dr. Randy Lehman (30:39):
So I would agree, except that when you're talking at M&M as a resident or as a attending surgeon with
new information, I think it's very important to never say, I would do everything exactly the same way
again because that is hubris and you're talking about a complication. You have to come up with
something at every M&M
Dr. Amy Vertrees (31:06):
That's judging yourself with new information. So that is the part that I think that we have to be careful
about is going back in time to say, I see the decision. What was I missing is completely different than
saying I would do everything the same because we had that information at the time. Now going back in
time, we now have new information, and of course we would make a different decision. It doesn't change
the fact we didn't necessarily have that information at the time. It's a very big difference.
Dr. Randy Lehman (31:35):
Yep, yep. We're saying the same thing. So the other thing that I would like to say before we get started on
how exactly you do the lap cases is in my practice, if I have a man with a unilateral initial inguinal hernia,
my practice is to do open first and my personal recurrence rate is lower with open than it is with
laparoscopic. And although there's studies that have been powered such that they say there's no difference
in recurrence rate, usually in the studies when you look at the actual raw data, the laparoscopic does have
a higher recurrence rate than an open. They're both low single digits. They're both lower than the maybe
20 to 25% of just a tension Bassini or McVay non mesh repair. So the big difference is you've got to do a
mesh repair in 2025 to decrease the risk down to low single digits.
(32:35):
I do think it's a little bit lower recurrence rate with an open repair. And I know personally for me, it has
been even some of these giant, and especially if they're giant inguinoscrotal how you're going to do that
laparoscopically and not have a huge, you're going to have issues with seroma hematoma no matter what.
But for me to reduce it, it feels a lot safer and better. So just saying, that's my practice, but not right or
wrong to do plan to go laparoscopic on everybody too. So any thoughts about that before we dive in?
Dr. Amy Vertrees (33:11):
I think the main thing is what you got training in, and this is where what we mentioned before is the best
repair is the one that you can confidently do. And I don't believe that a lot of people are confident with an
open inguinal hernia repair. I was lucky in my residency we had plenty of training on that, and there were
several people who really believed in open inguinal hernia repairs. But it is a challenge, and I think one of
my chief residents said it best, he said, open inguinal hernias are the one that you let the intern do, but
only the chief understands. I am fairly certain that the interns got the cases because the attendings really
wanted to do it. And if you have an intern there, you can pretty much do it because the intern just wants to
pretend like they're doing it. It's just my personal opinion.
Dr. Randy Lehman (33:56):
I hear what you're saying. Yeah. I definitely feel more comfortable with an open inguinal repair than I do
with a laparoscopic repair. And so maybe that's where I'm coming from for sure. Thanks for joining us for
this first of a two-part series, Dr. Amy Vertrees about the topics of autonomy and all things rural surgery.
And join us next time so that we can talk about a topic I'm sure that you're going to be interested in, which
is how, why on inguinal hernia. Thanks for joining this episode of The Rural American Surgeon Podcast.
