EPISODE 55
The Real Tradeoffs Between Robotic & Laparoscopic Surgery | Dr. Amy Vertrees Pt. 2
Episode Transcript
Dr. Randy Lehman (00:00):
Welcome back to the Rural American surgeon. This is the second of a two-part series with Dr. Amy Vertrees who gave us so much gold in her first interview that I just had to keep it all and we have to talk today about the inguinal hernia dos, don'ts, hows, whys and everything in between. Let's get into the show. Go. Let's talk about exactly now. So say we've got somebody with a initial [00:00:30] bilateral inguinal hernia and we'll say it's a man to make it all easy and you've made the decision now all that's behind us to come to the operating room for a laparoscopic versus a robotic inguinal hernia repair. And what makes the difference? Who gets lap and who gets robotic for you and your practice?
Dr. Amy Vertrees (00:51):
Well, that's a great question. So when you think laparoscopic, you're going to have TEP or TAPPS and TEP is going to be mostly laparoscopic. I don't know of, [00:01:00] I've not really heard of people doing robotic TEPs but of course you can. I typically do taps now because I do the same as I do robotically, which is through the abdominal cavity. You pull down the peritoneum and then you put the mesh in place. The biggest difference between a laparoscopic and robotic tap repair is the robotic arms bend on the inside. It's a lot easier to sew things and the visualization is a little bit better. So when it comes to what I prefer, [00:01:30] robot is what I would prefer because I find it simpler and easier. I'll go through each of the principled steps of both operations and compare the two because then you can see the main differences because in one hospital I have access to the robot and the other two I don't. So it really depends on where the person is of which one that I choose. That's typically my choice now.
Dr. Randy Lehman (01:54):
So let me pause. So basically if you have a robot, you're doing a robot, otherwise you're doing a lap.
Dr. Amy Vertrees (01:58):
Correct.
Dr. Randy Lehman (01:59):
But it's not to [00:02:00] the point where you make somebody drive to the robot?
Dr. Amy Vertrees (02:04):
No.
Dr. Randy Lehman (02:04):
Okay, very good. So which one do you want to start with?
Dr. Amy Vertrees (02:08):
So I'll start with actually both because I think they're both a similar approach. So both of them, the main principles of the operation are you want to give yourself as much room as possible. So the main challenge you can have as someone who has a short torso that where you're going to put your ports. I like to put mine as high as possible because laparoscopically you may be a little far away, but I haven't really found [00:02:30] that as a problem. Robotically, you have the ability to extend the arms there too, so the further away you are, the more space you're going to give yourself. So I tend to start access at Palmer's point in the left upper quadrant. So if I'm using the robot, I'll use the veress needle and then put the port in. If I'm using laparoscopic, I'll do optiview. So either way I access in the left upper quadrant, Palmer's point, so my other
Dr. Randy Lehman (02:55):
Two. When you come in optical laparoscopically, do you have any gas on the port [00:03:00] as you go in?
Dr. Amy Vertrees (03:02):
Yeah, I do. I mean I can do 'em both pretty fast, so if I do optiview, a lot of times I'll just optiview, then put the gas on and so I guess,
Dr. Randy Lehman (03:13):
So is the gas hooked up as you're coming in optically or is it you put the cord in first and then put the gas after you feel like you're in the abdomen?
Dr. Amy Vertrees (03:22):
As I'm talking through it, it's like, no, not typically. Now I will keep the gas on if I'm doing it for the gallbladder, [00:03:30] but typically I just access OptiView without gas.
Dr. Randy Lehman (03:33):
Okay, got it. Thanks. Just a little nuance question.
Dr. Amy Vertrees (03:37):
It's so funny as I'm teaching my junior residents things, it's so funny because they asked me how I do stuff. I was like, hold on, give me a second. I got to retrace my steps here because so many things become automatic. I don't even remember.
(03:48):
So I access left upper quadrant, Palmers point. The other two ports are at least hands with the part. I do try to put the ports within the rectus muscle, try not to do it in the midline, so [00:04:00] I'm decreasing the risk of having a hernia recurrence there too. So typically I'll have just the three ports, the camera in the middle, and then the next step is going to be taking out of the peritoneum. So whether I do that with hot scissors laparoscopically or with scissors for the robot, it's the same case. So you want to also make sure that you're not shorting yourself on the flap because it's so much easier to pull a flap down than it is to pull the flap above and you want to have enough [00:04:30] flap that you're going to be able to cover the mesh. The biggest challenge with that is that the peritoneal layer is going to be very thin, so the more you tear it, the more you got to repair it.
(04:40):
So it's a little bit easier to repair holes robotically, it's a little bit harder laparoscopically because you're either using a suture, which is a little bit easier with the V-Loc™, but it's still a straight stick, two dimensional screen, so it's kind of a pain. Usually in the end when you're closing the peritoneal flap, you're going to be using [00:05:00] a tacker laparoscopically and that can cause pain with sharp shooting pains if it irritates the muscle. And also you have the run the risk of gaps in the peritoneum. So the nice thing about the robot is that you can sew completely the opening very quickly compared to if you were trying to sew it laparoscopically and also you run the risk of just adding more expense to each of the case too. So the idea that you don't want to necessarily use all the laparoscopic equipment that you have or all the robotic [00:05:30] equipment you have, keeping it simple and easy is also going to keep it more affordable. There's the phrase that you do it, you do it safely, you do it well, you do it cheap or something like that.
Dr. Randy Lehman (05:42):
Yeah, in that order, sure, exactly. Sure. So what mesh do you use?
Dr. Amy Vertrees (05:47):
So I've used a couple different ones. Right now I'm using the ProGrip™ because they say you don't have to tack it. That's a lie. I always tack 'em because the biggest problem laparoscopically you're going to have a [00:06:00] recurrence if it rides up. So the pro or another ProTech, the ProGrip™ was sold as, you don't have to tack it because it's going to secure to the tissue and what I have found is it still rides up if you're not careful. I always secure to Cooper's Ligament and laparoscopically. I'll do that with a SecureStrap™ and robotically I'll sew it with a Vicryl just like a two Vicryl.
Dr. Randy Lehman (06:26):
So it's still absorbable with the thing that you secure and you think that [00:06:30] the scarring around that area most likely is strong enough to hold it medial where it's supposed to be so there's no recurrence, right?
Dr. Amy Vertrees (06:38):
Correct.
Dr. Randy Lehman (06:39):
Okay, very good. And so you're using ProGrip™ both laparoscopically and robotically?
Dr. Amy Vertrees (06:45):
Yes, and I've used the Bard 3DMax™ mesh. I actually like that, so I think the Bard 3DMax™ is a little bit more inexpensive than the ProGrip™, but it's just what we have at [00:07:00] the hospital. You sort of get used to it. So one hospital has Bard,
Dr. Randy Lehman (07:02):
Probably depends on your contract too, but yeah,
Dr. Amy Vertrees (07:04):
Yeah, exactly. One hospital has a Bard 3DMax™, the other one has the ProGrip™ and I'm comfortable with both.
Dr. Randy Lehman (07:08):
Yep, got it. So you've got the peritoneum peeled down either way we talked about the port placement. I want to go back just one second. Palmer's point, your access point, what are you using there? Is a camera going there or is that actually your left hand?
Dr. Amy Vertrees (07:25):
It'll be my left hand.
Dr. Randy Lehman (07:27):
Okay, so that's pretty high and [00:07:30] you don't have a problem reaching all the way over to do a right inguinal laparoscopically if you start at Balmer's point. What about a person that's a longer, do you do it different if they have a longer torso?
Dr. Amy Vertrees (07:44):
I haven't really found that much difficulty reaching and laparoscopically, so actually as I'm thinking about this laparoscopically, I don't always have the camera in the middle, which is what we usually do. Sometimes I'll put the camera to the further side so my arm isn't reaching over either [00:08:00] one works.
Dr. Randy Lehman (08:01):
Got it. Then where do you bring your mesh in and what are the sizes of your ports? In both cases
Dr. Amy Vertrees (08:09):
I typically start with three fives and I don't technically have to upsize one of 'em. What I'll do is I will take one of the trocars and go through the other one, so enter the far right and then go through the far left. I will pull the port out and I'll pull the mesh through the area, not to [00:08:30] the port
Dr. Randy Lehman (08:31):
To do it through the port. Just take the port out and pull it straight through. Yeah, yeah. I can't get it to go through a five and so then you're getting by getting rid of the five, I use a Hassan and then bring the port in through there or bring the mesh in through that port, obviously then you got to close that defect and you have potential risk hernia there and whatnot, but quite low. Could
Dr. Amy Vertrees (08:50):
You place Ioban™ on there? Don't necessarily always have to the inguinal but out of habit. I always did that for the laparoscopic ventrals because I do think, and it's a fair argument that you [00:09:00] are pulling mesh with skin nearby if you do to the port, it's kind of like a wound protector, but I've not had a problem.
Dr. Randy Lehman (09:06):
Yeah, okay. And then are they eight millimeter ports on the
Dr. Amy Vertrees (09:12):
Eight millimeters in the robot all, which is why I tend to avoid the midline.
Dr. Randy Lehman (09:16):
Does it go through an eight millimeter port? Your ProGrip™?
Dr. Amy Vertrees (09:20):
The ProGrip™ will
Dr. Randy Lehman (09:21):
And is ProGrip™ sized medium and large or how are the sizes?
Dr. Amy Vertrees (09:26):
They usually do like a 15 by 30
Dr. Randy Lehman (09:29):
And
Dr. Amy Vertrees (09:29):
I will [00:09:30] either, if it's a big hernia, I'll keep it at 15 and a lot of times I'll cut it down to 12 or 13 and I always round the corners because getting the mesh lay flat, those corners really don't really add much to the repair, but they do kind of sometimes curl up and I never want that to be a lead point, so I always add a little curvature to all corners.
Dr. Randy Lehman (09:51):
Okay, and what landmarks do you use then after you get your port placed and you're using your scissor to take down the peritoneal flap, where do you start and [00:10:00] do you score it with cautery and then follow the lines.to dot for yourself or any special tricks like that?
Dr. Amy Vertrees (10:06):
Yeah, that's a great question. So I always try to start further back because if I get a small hole in the peritoneum, then I'm still going to cover the mesh, especially laparoscopically. So I usually just take the scissors and just go straight across. I don't score it. I'll pull it out just a little bit and as soon as you open it, the pneumoperitoneum will open up that space somewhat, so you'll see it starts to develop that plane. [00:10:30] So I pull up gently because it does tear easily and I mostly will do it sharp or robot is a little bit easier to lay on the cautery because you could see the layer so much, but it's usually this loose areolar tissue that really shouldn't have a lot of vessels within there. So if you're in that plane where there's loose areolar tissue, it's mostly just cutting the peritoneum then gently pulling it back and then following that loose areolar tissue.
(10:55):
So then it can be a little bit challenging to figure out where to start. So the landmarks, [00:11:00] I'm always aware the midline is the symphysis pubis and also where the anterior iliac spine is, so we can externally put some pressure on there to see where they are. I typically will start in the safe place. I always told the residents that there are safe moves and there're safe places. The safe places are in the midline and lateral safe moves. So when you go in the middle near the inferior epigastric, so I will usually just follow wherever the loose aerial or plane takes me and when I get to something that is [00:11:30] confusing, then I'll start and find the symphysis pubis and that side and then I'll find the lateral side and then know, I know in the middle there's going to be the rest of the stuff.
(11:41):
And then especially if you have a big direct hernia that is incarcerated and then you're trying hard to figure out what things are, you think of the things that don't vary. Symphysis pubis doesn't vary. The inferior epigastric you can find in the anterior sphere, iliac spine, you can have external pressure to find that. So once I find those things, then typically [00:12:00] what I'll do is I will follow the inferior epigastric down to where you see the spermatic cord structures. They kind of take a curve. So what I do in that move especially, let's see direct, this is where it gets confusing if there's a direct, so I'll start with direct first. If I find the inferior epigastric, the stuff medial to that, if it's on the right is going to be direct. So then I know this is probably if I don't see any organs nearby, this is probably just a plug of fat or something like that. So you could be a little bit [00:12:30] more aggressive in pulling that out as long as you're medial to the inferior epigastric.
Dr. Randy Lehman (12:35):
How does the medial umbilical ligament factor in as a landmark? Because I find it's often hanging down. This would be the obliterated umbilical vein. Correct.
Dr. Amy Vertrees (12:50):
So I take my left hand to lift it up, I take my right hand tip to tip and then I move it directly to the right, and what that does is it [00:13:00] separates the things posterior to it. There was a time when we were kind of wrapping the cord and I did that for a period of time when that was sort of a technique people were using. I don't do that anymore, but it was useful to be able to dissect circumferentially around the spermatic core structures. So that technique of lifting it up and then spreading it to the right, separate out from the tissue behind it, so it wasn't so confusing. So then what I did was I took my left hand, I pulled it back just a little bit, let the cord structures [00:13:30] drop and then lifted it up and then I did tip to tip and I traveled parallel to the spermatic cord structures a lot of time that would then snag the hernia sac.
(13:42):
Then at that point I'll see where the hernia sac is because as soon as I can identify what a hernia sac is, then I work, I don't really worry about the spermatic cord. I grab the hernia sac and I basically take everything off of the hernia sac from the cord. The main thing is whenever possible I try to grab [00:14:00] on the adhesive side of the hernia sac. So now when I take these little small bites, it's a thousand little small bites rather than big tears. So if I'm just like pull, pull, pull, pull, that actually goes much faster than if I try to grab a big bite and tear it.
Dr. Randy Lehman (14:16):
Great. So then as you continue to peel it down, how do you know that you're low enough on your fold that you're ready to bring your mesh in that groove?
Dr. Amy Vertrees (14:24):
That's a great point, and whatever it is, whenever you think you're done, do a little bit more [00:14:30] because love it. I have put the mesh in prematurely enough times and tried to dissect it with that mesh in there enough times to be so painful that I dissected a lot more. So usually now I can pretty much eyeball it, which is not really helpful for someone who hasn't done it for a while. But I can say really what you want to do is you want to be able to grab the hernia sac and then hand it off to yourself so far in advance that it's going to cover. When that mesh goes in there, it's going to cover the femoral space, the direct [00:15:00] and the indirect space, and when you lift up that peritoneum, it's not going to curve the edges of the mesh because that's really where recurrence has happened is the bend of the mesh at the back. So the more you could have your mesh lay flat not near any kind of lead points that could lift and keep in mind that that abdominal wall is going to move somewhat, that you want to make sure that the sac is way backward, that if you pull that sac, it's not going to be messing with your mesh at all.
Dr. Randy Lehman (15:30):
[00:15:30] How often do you see the iliacs actually see them in your dissection? You try not to do that, or does it really bother you when you're coming down on the deep inferior epigastric, you're eventually going to get to it?
Dr. Amy Vertrees (15:42):
That's a great point. Almost every single case actually, because finding cooper's can be a little bit of a challenge. I found that the symphysis pubis and the cord structures, it's almost always directly in between. There is [00:16:00] the Cooper's ligament, so obviously it's going to be medial to the inferior epigastric vessels, so that's one thing that you're going to see. But I usually do like the midline and the core structures. Cooper's going to be directly in the middle of that too, so I always clear off Cooper's their by the way is almost always at least an annoying vein if not the Corona mortis, which is obviously can be life-threatening. So I think it's really important that you see Cooper's to be able to confidently secure it because [00:16:30] it really is right next to the iliac vein and so you want to be very careful that you know exactly where things are and so I always clear off where Cooper's is because I intend to adhere to it.
Dr. Randy Lehman (16:44):
Great. So if we can take one second on the cor mortis. So if you get bleeding when you're dissecting on the pubic tubercle AKA Cooper's ligament, what are your first steps and then what if that doesn't work your [00:17:00] next steps?
Dr. Amy Vertrees (17:01):
Yeah, it's a great question. Usually the way that I dissect it, I'm pulling it away from it. So where you get in trouble is that if you don't clear it off from when the hernia sac is pulling off, if you're not careful as you're pulling off the peritoneum, then first if you pull it carefully back then usually what you're left with potentially is like little fat blob where the Cooper's ligament is. And so if you indiscriminately [00:17:30] grab that and tear it, if you tear any fat in that area, it's going to bleed. So the first thing is to gently grasp something and give it a little bit of tension and cut things that you can see rather than pull fat, especially in that area because there's almost always going to be that annoying vein that's going to be exactly where you want to put attacker. And most of the time it's not going to be an artery, it's going to be that
Dr. Randy Lehman (17:55):
You cut it with cautery,
Dr. Amy Vertrees (17:58):
I will typically do [00:18:00] with cautery. So when it was laparoscopic, a lot of times I would have just the hot scissors, things like that. And so typically I would burn in that area. So now well the robot is a lot easier. It's a lot easier to see and also if you're questioning it all, you can suture it over, sew it, but that's much easier robotically than it is laparoscopically.
Dr. Randy Lehman (18:24):
So say you're laparoscopically and then you got into bleeding there and then you try to treat it with [00:18:30] cautery and then it's still bleeding and maybe it's like pulsatile bleeding, but it's kind of retracted.
Dr. Amy Vertrees (18:39):
But usually they'll have a five millimeter clip applier. So I haven't really gotten into that, but this I can imagine what I would do, the biggest thing is that I don't want to buzz anything that I can't see, so you don't want to burn anything if you only partially see a vessel. I mean I really should see whether that's an artery or vein or not. And so I don't usually use cautery unless I can kind of see what that is and in [00:19:00] the short term, you can just take a grasp or hold it for a second. And especially if you're encountering a lot of bleeding, the very first thing is just to put pressure on there, take a deep breath and ask yourself what do I need next? So having hot scissors on there is probably going to be true for any of the cases that you have.
(19:18):
Then your other avail things are going to be some more cautery type instrument like a LigaSure or something like that. I mean I don't think you'd necessarily need that, but knowing asking yourself, is that what [00:19:30] I need, a five millimeter clip applier should be readily available in these cases always on my possible thing, how I close the peritoneum openings when I have it laparoscopically, and so I think typically it would be first pressure, then expose it, then electrocautery. If it's small, then five millimeter clip proply. If it's bigger, then suture repair if you really have a hard time, but you definitely want to make sure that nothing is [00:20:00] actively bleeding because what'll happen is it can go into that hernia space and it'll present as a very large scrotal hematoma.
Dr. Randy Lehman (20:08):
And you talk about holding pressure and kind of pinching it, but I like to ask, do you ever bring a EC in and hold pressure that way?
Dr. Amy Vertrees (20:15):
You can. Typically you're going to need at least a 10 port for a ec, so you'd have to have an upsize port, and I think this is where a lot of people get into trouble is if they have not asked to have all these things available. So [00:20:30] whenever you're doing a case like that, most of the time it's going to be a straightforward laparoscopic al hernia repair, things like that. But you always want to plan for what if. So on my what if things are going to have things like an upsize port and the five millimeter clip applier and an endo loop. If I'm having trouble closing the peritoneum, which is the five millimeter clips alone, then Tex are always available. But again, you'd have to have a port side. So what I think what fluffers [00:21:00] people is not that they can't manage it, is that it feels like the decision fatigue and the overwhelm as they realize I got to ask for this and it's taking a long time and I'm looking at this meeting, you can prevent a lot of that ahead of time.
Dr. Randy Lehman (21:13):
Yeah, very much agree. But the ray tech is probably one of my bigger things, but I have the 10 in there,
Dr. Amy Vertrees (21:21):
So then
Dr. Randy Lehman (21:22):
I just dropped the rate. Tech always can just be calm and catch your breath if you have any bleeding or whatever. So that's [00:21:30] great. So you said you see the iliac almost every time because that's kind of part of how you know that you get low enough
Dr. Amy Vertrees (21:36):
To Cooper's
Dr. Randy Lehman (21:37):
To summarize that. Very good. And then you're going to bring your mesh in and secure it medially to Cooper's ligament. You talked about how you were going to do that and beside them, is there some other step in between there?
Dr. Amy Vertrees (21:52):
Yes. Before I put the mesh in place, and I did this mostly because I taught residents for most of my early career and we had the [00:22:00] Bard 3DMax™ mesh, they have a nice curve, but even with the ProGrip™, it helped me teach resins, but I think it also helps orient. I draw a line where the ILI pubic tract is and I draw a line where the inferior epigastric is going to be. I draw a circle where I expect a direct, a circle where I expect the indirect, a circle where I expect the femoral. So when I stick the mesh in there, it's like I just want to make sure the holes line up where they are. That keeps it oriented because I think the biggest challenge when you're doing inguinal, [00:22:30] you're at a bit of an angle and so if you're at a bit of an angle, you can potentially get the horizon off. But if you draw the line and you look at the anatomy that doesn't vary and you draw the circles where things are supposed to be, that's going to keep your mesh aligned and it's not going to be drifting too far south or too far north.
Dr. Randy Lehman (22:47):
Perfect. So now you've got it labeled and robotically that you just roll up and put it through the port, right? Correct. You bring your mesh in, but laparoscopically though, you're bringing [00:23:00] it in through take your port out, right? Yeah. Okay. So then you bring it in and then you secure it. The starting point is getting it all oriented and then securing it medially either with the secure strap or with a Vicryl. Is that a 2.0 Vicryl or?
Dr. Amy Vertrees (23:16):
Yeah, typically I'll do like a 2 0 3 oh is fine too. So robotically I'd have a two oh Vicryl for cooper's and also to close any of the defects if I had one in the peritoneum, and then I'll close the peritoneum with a [00:23:30] V lock just because you don't have to mess with the tying the ends, so you can't actually do that laparoscopically with that suture and it has been a little bit more helpful. But honestly, those, we just put the tacker on there, so I tack the mesh of Cooper's and then medial and lateral to the epigastric, but making sure that the mesh lay is flat because another thing, a mistake that you can make is attaching it and the mesh is not exactly flat, so I make sure that the mesh is flush with it, the abdominal wall exactly where I want it [00:24:00] to be tack at a cooper's check that is flat again and not twist it off the horizon and on either side of the epigastric and that secures it in three places and that keeps that mesh where I want it to go.
(24:12):
Then I pull the peritoneal flap up and then tack that in place. And that can be difficult if you have a thin peritoneum or multiple tears. Then if there's multiple tears laparoscopically, then what you want to do or bigger one, I lift up the corner of the hole. I use a five millimeter clip applier [00:24:30] to close it, and if it feels like it's under tension at all, I'll end an endo loop on there just to make sure that that hole in the peritoneum doesn't happen. I have seen, it wasn't in mine, but I saw an Eminem where someone had a small bowel obstruction through one of these small defects. So I do try to close all of them.
Dr. Randy Lehman (24:47):
Very good. And then trying to keep those tacks out of the old triangle of doom and triangle of pain.
Dr. Amy Vertrees (24:52):
Correct. Yeah, don't touch that stuff at all.
Dr. Randy Lehman (24:56):
Triangle of doom for the learning [00:25:00] listener being the space where you see this triangle going towards the internal ring, which is your VAs deferens or round ligament medially, and then your gonadal vessels laterally, just don't go down below there and then laterally where you have your spermatic vessels and then up to the iliopubic tract is your triangle of pain, so don't take him down too close to the cord and just stay up above the internal ring and you're generally going to be in the safer zone. [00:25:30] What else do you have to add to that? That was an awesome overview of laparoscopic and robotic repair.
Dr. Amy Vertrees (25:38):
Oh, thank you. Yeah, I really enjoy those. I will say the difficult challenges could be if you have a large hernia sac. So a couple things that I would keep in mind, if you remember what the principles are that you have to do, you need to pull the peritoneum back and put the mesh on there. So I would not kill yourself finding a huge hernia sac. [00:26:00] I would do the best that you can to resect the whole or pull the whole thing back. If you pull the whole thing back, then there's not a hernia sac that could hold fluid within a large inguinal space. So first, as I try to get the sac out, if I believe that I pulled out enough hernia sac that I can adequately cover the mesh and I could lift the sac away from spermatic cord structures, I actually don't really have a problem cutting that sac and repairing it as long as I'm going to have enough coverage of mesh.
(26:29):
The [00:26:30] downside of that, you're essentially going to leave a end of the sac that can accumulate fluid, but even if you don't do that, the person is at risk of having fluid in that space. And early in my career, I chased down many of a palpable mass in the inguinal canal area. That was really just where the hernia was. So now what really helps postoperatively is explain this preoperatively. So someone comes to me with a large hernia, I'm going to say, okay, this is what's going to happen. [00:27:00] I'm going to pull everything away from that space. I'm going to put hernia mesh in there too. The fluid is going to go both sides because it's mesh, it's going to start sealing off. Fluid is going to be in that space. You're going to feel like you have a hernia, you feel like you can have a hernia back that is fluid, give me a few months.
(27:17):
So I found it takes at least three months for that to get better. So if they come into the office and they have this feels like my hernia, I hold my hand there and say, alright, cough for me. If it doesn't move with Valsalva, I do [00:27:30] not do anything, come back in three months. So I would not jump to the conclusion it's immediate recurrence, but you do want to have that as a possibility in your mind, but almost always it's going to be fluid, especially it's going to fill that space that you had. So I tell people to expect it, especially men too. I'll have them wear a jockstrap and say, look, we need to keep that space closed as best we can. So fluid doesn't develop. I tell them to roll up a hand towel and use gravity to keep fluid from building up in that [00:28:00] hernia sac space. And those are the things that I do is both warn them ahead of time and afterwards and definitely warn people that they're going to have black and blue and nothing's going wrong. It's going to be very impressive and you can call me if you want, but I'm going to tell you what's fine.
Dr. Randy Lehman (28:15):
Right, exactly. So even for a very large inguinal scrotal that's as big as the patient's head, that does not scare you and you go laparoscopic.
Dr. Amy Vertrees (28:26):
Yes, and with a couple things, especially laparoscopic, [00:28:30] I would probably just put more T around the opening. Obviously still avoiding the triangle of pain, but in that particular case laparoscopically I was securing them in different spaces. Now robotically, you can't potentially narrow that space a little bit more, but then typically what I do is I just sow the mesh around it because really what you need is that mesh to kind of hold that wall in place. The biggest challenges with occurrences are typically the mesh rides up and it [00:29:00] goes underneath there too. So even recurrences, a lot of times you can go back minimally invasive, almost always going to be underneath the mesh. So then making sure you have it adequately down. The bigger meshes can be a problem if you don't have adequate coverage superiorly. So you want to make sure that you have adequate coverage superiorly, and also I secure it in place to give us a finding shot, but that's where the Bard 3DMax™ the extra large is going to be helpful or I'll keep the ProGrip™ at 15 centimeters.
Dr. Randy Lehman (29:30):
[00:29:30] Yeah, so you actually close the hernia sometimes robotically, but never laparoscopically.
Dr. Amy Vertrees (29:38):
For one thing, it would be really hard and a lot of times robotically it's hard to necessarily close that space and expect it to stay. So I think it's, well,
Dr. Randy Lehman (29:47):
You're not doing a real McVey or a bini. You're not taking two structures like the inguinal ligament and stitching it to cooper's or stitching it to, [00:30:00] so you're not grasping basically the conjoint tendon and bringing it down to one of those two structures, inguinal ligament or cooper's ligament.
Dr. Amy Vertrees (30:07):
I'm not,
Dr. Randy Lehman (30:08):
I mean not just you. I'm saying anybody that was doing it laparoscopically. So then it's not really, you're just kind of tucking it together. But in my mind it would make sense to do that, to keep it that way so that it scars that way. It's not that you're counting on that. And that's the same reason when I have a large direct defect that I'm doing open. A lot of times I'll do a bini [00:30:30] and then stitch the mesh over the top because you're just getting it out of the way.
Dr. Amy Vertrees (30:34):
Exactly.
Dr. Randy Lehman (30:36):
Okay, that sounds good. And what about the pneumo scrotum? You just squeeze at the end of the case the scrotum and get the air usually out, or
Dr. Amy Vertrees (30:45):
They can be really remarkable though. One thing that you can do to decrease this to some degree is you don't necessarily have to have it at 15 millimeters mercury for your pneumo peritoneum. So I think that anywhere from eight to 10 is actually okay, especially once you [00:31:00] get started. But afterwards, this should be CO2, it should absorb quickly. And so usually we just try to compress the gas so doesn't surprise 'em when they wake up.
Dr. Randy Lehman (31:10):
And
Dr. Amy Vertrees (31:10):
Also just the drop strap because that gas is going to be replaced with fluid and that's really the problem.
Dr. Randy Lehman (31:17):
And so when do you image, I mean obviously if you think there's a recurrent hernia, you would do it right away, but you wait three months, something's still there. Do you image there if something's still there? And then other questions, when do you aspirate? [00:31:30] When do you I and d?
Dr. Amy Vertrees (31:32):
I don't aspirate fluid at all. If it's infected, that's definitely a different problem. Then you would have to worry about the mesh. I haven't experienced that yet. Typically what I'll do is on my post-op visit, I will usually have an idea how big the heart was before. If my fluid sac approximates that and it doesn't move with the Valsalva, it's going to be a seroma. So then I'll bring them back in three months to see how things are. And if it's [00:32:00] documented as smaller, then I was like, just stay the course. Is it bothering you? No, stay the course. And if I do any imaging, I have an ultrasound on my office, so I trust my ultrasound imaging more so than sending 'em off because usually when I send off for ultrasound of the groin, they say, lymph nodes look all fine. I'm like, that's not what I was going for, but I've got an ultrasound in my office so I can identify it in real time, have them valsalva themselves, things like that. I find that much more helpful than [00:32:30] an ultrasound someone else does. And CT scan I don't find hugely helpful unless you have a big recurrence and that's usually probably something that you're going to be able to see.
Dr. Randy Lehman (32:37):
Yeah. What kind of ultrasound do you have? You have
Dr. Amy Vertrees (32:39):
It is a Terran something or other? I got it back in 2020.
Dr. Randy Lehman (32:45):
Yeah, that's actually coming from military that originated with a military unit and then now it's become a terran.
Dr. Amy Vertrees (32:53):
Yeah, yeah, it was one. I have one too. More inexpensive but still good quality. And you bought it new. It's basically an extension [00:33:00] of the physical exam. Very helpful.
Dr. Randy Lehman (33:02):
Did you buy it new?
Dr. Amy Vertrees (33:04):
I did,
Dr. Randy Lehman (33:04):
Yeah. Instead of a car. Yeah, right. I think that's what was, mine's like 25 grand or something like that.
Dr. Amy Vertrees (33:10):
I think it was like 25.
Dr. Randy Lehman (33:11):
Yeah. So basically do you bill for that? Do you put a report or capture images or anything?
Dr. Amy Vertrees (33:18):
Yeah, so to bill for an ultrasound that you use, you need to take pictures and you have to have the ability to submit them if they ask. So I could, but I often don't to [00:33:30] get the, and that's mostly making a executive decision is not worth my time to do it because the most I'm going to get is $20 or less. It's going to take me an hour to figure out how to do it.
Dr. Randy Lehman (33:42):
Yeah, and do you let it raise the level of your e and m by one or something like that? If you're using intraoperative ultrasound, does it factor in like that?
Dr. Amy Vertrees (33:52):
No, usually I'm using it in the post-op period and to be in the global anyway, so you really couldn't charge for that anyway. I do it as an extension [00:34:00] of physical exam and then in that case I usually just do that as an extension of the e and m.
Dr. Randy Lehman (34:07):
So I've recently had some discussions with my best friend Chad, GPT, and some coders about, just because you brought this up post-op coding and I have been, so is a seroma complication of inguinal hernia. It
Dr. Amy Vertrees (34:27):
Doesn't matter. The only thing you paid for is if there is [00:34:30] a operative intervention. I think I could be wrong, but
Dr. Randy Lehman (34:33):
That was what I have always done, but I'm being told that it's not true. So basically you get paid for managing a complication and the 90 day global is only for routine postoperative normal postoperative course. So if the bottom of your note says anything other than routine postoperative course, there should be a modifier 24 and an ENM code.
Dr. Amy Vertrees (34:59):
I think it makes it more complicated [00:35:00] because some of the hernia codes don't have globals anymore and I can't remember, I think the ventrals don't have globals anymore. The ALS do is complicated.
Dr. Randy Lehman (35:10):
That is correct, yeah. So anterior abdominal wall is a new block based on size and based on if it's initial or recurrent and incarcerated or not. And if that's the only one you did, then they dropped all of our values and in order to tell us that that was okay, [00:35:30] which it wasn't, and nobody asked me, but they gave us our post-op appointment. Now patients, you have to explain that to them because they're expecting now that to be part of your included global, you just have to explain nope, in their infinite wisdom, the whatever you call it, I can't come up with it right now, the task force that decided this, they said we are decreasing the value, the price of the inguinal hernia [00:36:00] and we're giving you that back. So that is now part of it. You just have to explain it. The question is what do you do if it's a routine recovery and you did a umbilical hernia repair and a bilateral inguinal hernia repair, and I've always put that in a global, but I'm now being told that you should tie your note to the umbilical hernia and put a modifier 24, and that should be a billable visit.
(36:26):
So talk to your own coders. I mean it's kind of like [00:36:30] talk to your accountant, talk to your attorney thing. I'm not a coder, but that's how I'm doing it.
Dr. Amy Vertrees (36:36):
Well, it's what you can code for and what will get paid. It is sometimes a big difference,
Dr. Randy Lehman (36:41):
But if you put the inguinal hernia, ICD 10 and you tie it, then it's going to kick out. But if you don't put your ICD 10 for your inguinal hernia and you just put your ventral hernia code in, for example, or if your code is seroma or hematoma, then you get paid [00:37:00] for managing complications basically is the message. Very. So anyway, that is a lot of great information. I think we should move on to the next segment of our show, which is actually the financial corner. I was wondering if you had a money tip for our listener.
Dr. Amy Vertrees (37:18):
The biggest tip that I have is know what your math problem get coaching? What's that?
Dr. Randy Lehman (37:23):
Get coaching?
Dr. Amy Vertrees (37:24):
Yeah. No, actually it's simpler than that. I just had a webinar called math not drama. [00:37:30] So the most important thing that has to do with money is know what your money story is and a vast majority have no idea how much things are getting reimbursed. And it's by design. If you're employed, it means someone in the hospital is determining that. And if you have private practice that is based on whatever your insurance contracts are, there is a way to figure out how much you're getting paid. The problem is most people don't know what that is. So my financial tip [00:38:00] is to be interested in these things and not overwhelmed by it. And I would especially, so if you're employed, then I would meet with your biller and coder and say, tell me more. Just exactly like you described. Be curious about that. So first know what the revenue cycle is.
(38:16):
You basically see a patient that is you generate an invoice, which is your note, your invoice has on it, what you did, the diagnosis that you're treating, the ICD 10. [00:38:30] And then whatever you did procedure is going to be CPT. Your visit is going to be ENM, and that's basically your invoice for which you work. If you don't do your note, you don't get paid. So that is on you to not submit your invoice. And your invoice needs to be factually correct and it needs to make sense. You cannot bill for a service that does not solve a problem that you're asking for. So you have to make sure that your invoice is correct. So then you submit it and someone's checking your invoice coders and then the billers is sending it to the company and then there's [00:39:00] collections and you were paid by the weakest link. So that is the most helpful, which
Dr. Randy Lehman (39:06):
Could be you,
Dr. Amy Vertrees (39:07):
Which could be you. And oftentimes it's us because if we do not document on time, if we do not document properly, if our invoice is not in order, then it is typically we are the weakest link. Then it's going to be is it coded correctly, is it submitted correctly? And then is it actually collected upon, my kid had an ER visit and we didn't get a bill [00:39:30] until 11 months later. And oftentimes if you're not aware, it's like my invoice is perfect, but they kick it back for some reason. We want the path report, even though you sent it three times, then what'll happen is you won't get paid because they'll say, we don't have enough information. So you have to be aware, you will be paid by the weakest link of the revenue cycle.
Dr. Randy Lehman (39:50):
Be interested. That's beautiful. What gets measured gets managed.
Dr. Amy Vertrees (39:54):
Exactly.
Dr. Randy Lehman (39:56):
I love it. All right, let's move on to the next segment of the show, which is classic [00:40:00] rural surgery stories. You have story, a crazy story that we just wouldn't believe.
Dr. Amy Vertrees (40:05):
Oh yeah. So debate which one to do, but this one was interesting. The biggest challenge for this particular patient, this was a noncompliant patient who was not obese, who was a smoker, who thought they were obese and tried everywhere in the United States to get a gastric bypass, which of course no one would do. So they went to a resort in Mexico [00:40:30] and got a gastro bypass and they continued to smoke and then something happened but was also not compliant and didn't like doctors, the usuals kind of thing I can describe as a hissing cat. And so basically comes to the hospital just wasting away like skeletal and try to figure out what was going on. The anatomy was difficult enough and everyone's like, oh, no, no, send it to a bariatric surgeon. Well good luck when the [00:41:00] person doesn't have insurance that once they're admitted to a hospital. We tried to manage it and then said, oh, this is a little bit more complicated. So interestingly enough, because they were still a smoker, anastomosis had eroded into the colon. So basically it went from the gastric pouch directly into the transverse colon. So the person had been malnourished for probably six, seven months easily when this probably happened, six, seven, anytime the eight [00:41:30] would have loose stools. So initially saw the gastroenterologist who's like, I stick my scope in there and I see three holes.
(41:38):
So we tried to send it somewhere else, bariatric surgeon, things like that and could not get anyone to accept the patient. And so they called me because at some point that delicate combination of fistula that happened fell apart and the person is Thanksgiving weekend too a couple of years ago. And I was like, well, I guess we'll have to figure [00:42:00] out something. Anyway, in that time I found that where that fistula was, the gastric remnant to the transverse colon had fallen apart. And I was like, well, I mean I could fix this, but I mean really what this person needs is a reversal of their gastric bypass. In that moment, she was stable enough where I said her best option is to get as much nutrition as possible, and so just ended up reversing her gastric bypass. She was never obese in the first place.
Dr. Randy Lehman (42:30):
[00:42:30] She basically leaked. You're saying that when you say fell apart, she developed an acute leak right from that area? Correct. Which you would think that'd most likely be a perforated marginal ulcer, right? Could
Dr. Amy Vertrees (42:43):
Be
Dr. Randy Lehman (42:43):
Because I mean once you got established fistula, it's probably not just going to explode except for the fact that you've got that gastric
Dr. Amy Vertrees (42:49):
Juices there. The Marshall Ulcer eroded to the colon. The colon was acting as a patch was not there. I think that particular long had just been sort of manipulated endoscopically and I think [00:43:00] really just kind of eroded that not strong connection.
Dr. Randy Lehman (43:03):
What a crazy situation. Would you ever take a patient like that? They're sitting there, it's a catastrophe. You cannot get them somewhere. It's easy once it becomes an emergency, but would you ever take them electively for something?
Dr. Amy Vertrees (43:21):
So it's a good question. In this particular case, I think electively, we had different options, could stick a tube in [00:43:30] the gastric remnant and things like that. The main problem we have is a financial one. This person did not have insurance. I was trying to figure out a way to fix her as best as I could with as much as it can at the time. Electively wise, we would probably have gotten her to a bariatric surgeon to see whether fixing marginal ulcer, carafate, things like that. But in this particular case, it wasn't feasible. And I also [00:44:00] knew that not to be, how do I delicately say this?
Dr. Randy Lehman (44:07):
I can't wait.
Dr. Amy Vertrees (44:08):
Was not a provider, preferred person basically fired people left and right. Yeah,
Dr. Randy Lehman (44:16):
What a disaster. Yeah, I don't know. So how exactly did you reverse the gastric bypass and did you know how to do it and you just did it or did you talk to somebody?
Dr. Amy Vertrees (44:29):
Well, [00:44:30] I knew that I was going to have to repair the hole, so it is all just anatomy. It was actually not as hard as I was afraid it was going to be. So luckily because she was somewhat noncompliant, her gastric pouch was actually fairly large. So that's where the staple line was. It was likely a marginal ulcer. So what I did was I took down the staple line and I hand sewed the stomach to itself. Once we had that, then I had a hole in the colon, so I just resected that and connected it [00:45:00] back together and then repaired.
Dr. Randy Lehman (45:03):
How'd you do that anastomosis?
Dr. Amy Vertrees (45:05):
That one I did stapled.
Dr. Randy Lehman (45:09):
When you say stapled, did you do a anti peristaltic or how did you, does the transverse function come up side
Dr. Amy Vertrees (45:16):
Functional end to end? Yeah, so side-to-side, functional end to end.
Dr. Randy Lehman (45:20):
Okay. When you say that, I know you're saying that, but are you bringing the two in so it goes up to the end and then comes back?
Dr. Amy Vertrees (45:30):
[00:45:30] Yeah, I think I would say it would be anti peristaltic.
Dr. Randy Lehman (45:34):
Now
Dr. Amy Vertrees (45:34):
That being said is
Dr. Randy Lehman (45:34):
Because you could lay 'em side by side,
Dr. Amy Vertrees (45:36):
You can lay 'em side by side especially. So there's a really nice video from Mark Solomon that talks about robotically where you take two centimeters from the end, so you add them, lay them next to each other, and you start things like six centimeters or something like that, a little more than that and open it up and then staple it back together, making sure that, and then overs sow it. But [00:46:00] I just did the side-to-side functional end to end.
Dr. Randy Lehman (46:03):
I mean, if you're using a 60 millimeter stapler,
Dr. Amy Vertrees (46:05):
Six
Dr. Randy Lehman (46:06):
Centimeters, something of that size. So basically you hand sewed it together and I love that. And did you do one layer or two layers on your hand? Sewed and anastomosis of the stomach?
Dr. Amy Vertrees (46:17):
I did two layers, so I did the back wall limber two oh silk sutures, full thickness two oh Vicryl, and then did the outer layer of the two. Oh, silk Lambert.
Dr. Randy Lehman (46:29):
Yeah. [00:46:30] And on your inner layer, did you do that running?
Dr. Amy Vertrees (46:33):
Running?
Dr. Randy Lehman (46:34):
And so did you run from both sides and then tie on the front
Dr. Amy Vertrees (46:38):
Start in the midline and then basically two sides. So start the midline, go towards myself towards one to close it with canal stitches on the edges, and then also started midline and went away from myself as described in Cha's operative anatomy.
Dr. Randy Lehman (46:55):
There you go. Did you consult chasins prior to the case or [00:47:00] you got it your brain? Very good. Awesome. Well, I love it. That's a great story and I can't resist talking about the technical aspects, so thank you for indulging me.
Dr. Amy Vertrees (47:10):
Sure.
Dr. Randy Lehman (47:10):
Let's move on to the last segment of the show resources for the busy rural surgeon. So what is one great resource that you love that you just think every rural surgeon should know
Dr. Amy Vertrees (47:19):
About? I think everyone should know about the Boss Business of Surgery Series podcast and yours. Wow,
Dr. Randy Lehman (47:24):
Love it. Yes. So I guess I didn't say that. So Dr. Vertrees has her own podcast and [00:47:30] she's been quite an inspiration to me in terms of listening to what you put out there. There's a lot of stuff that's similar to what we're talking about. Of course, what I'm talking about is much more focused on rural surgery specifically you've had some rural guests and I would say that yours is more focused on the workplace environment and mine is more focused on specifically rural surgery and then potentially the technical [00:48:00] aspect. I like talking about that, but it's been so helpful for me listening to your show and you have then I also coach a lot, I've coached a lot over the past. We'll say I probably started coaching in 19, and I've always had some sort of a coach, sometimes more than one, and when coaching's kind the ambiguous term. But I've had coaches [00:48:30] in the real estate world, masterminds that I'm involved in where we're kind of coaching ourselves, go pod group. That's a group of people.
(48:39):
There's, there's no replacement for a parent that cares about you, a spouse that cares about you, that really understands the ins and outs and talking to them, but breaking away from that and actually coaching with somebody one-on-one. Also, if you pay somebody to coach you, it's almost like you value it, or at least I do value that time. So right now my active [00:49:00] coach is actually PT who grew a big PT business, and we meet twice a month basically for about 90 minutes a time. And I'm very strongly considering actually coaching Dr. Virtue, almost certainly. I'm going to do that because there's a lot of synergy there. But what is your podcast about and what is coaching before we wrap up and get out of here?
Dr. Amy Vertrees (49:27):
Sure, I'll keep it brief. So if you had to boss surgery.com, [00:49:30] that's where you find the podcast. And also I'm a coach as well. I've been a coach since 2020, the podcast and my book and my coaching all focus on the lessons not taught in residency. So I would consider myself more of a surgeon career coach, if you think of it that way, because we all have the things that we help with. So the podcast initially started with me, just myself, but what it turned into was an interview format, which has been far more interesting to me [00:50:00] and also more informative because whatever problem I find that I encounter, I'll find someone and we talk about it. And so Dr. Leman Hass been on there as well. Of course, we talked about rural surgery, the economics of rural surgery. And so I have over 200 episodes now.
(50:16):
My VA has actually gathered all of our topics, all the podcasts under specific topics. So now you'll be able to go to the website, it's almost finished, where you'll be able to go to the website and click on, okay, I need to deal with clinic, or I've got this difficult [00:50:30] colleague, or I'm looking at a career shift. So it's all the lessons not taught in residency. So things that you encounter when you go out after residency, and it's been very helpful to me. One of the more recent ones I think were really important is talking about emotional capacity. We talk about skills and knowledge, but we do not talk about the ability to manage the things that come up like dread and uncertainty and anxiety. And unless you find a way to manage that, [00:51:00] the emotional capacity, you have to expand that with things like gratitude and appreciation and inspiration.
(51:08):
If you don't have a balance of that too, this is actually what can decline in our career. And I think that's the biggest threat for most people. My coaching is a year long program, group program. I also do one-on-one coaching, but my group program is for surgeons and it's a year long. And the reason it's a year long is that there are certain things that I think that we really do need to know beyond residency. [00:51:30] And so I do three months of dealing with difficult colleagues. So how do people set us off? How do you deal with other people? How do you interact with this other people that are also doing hard jobs, which is essentially how do I manage my stress response and theirs?
Dr. Randy Lehman (51:44):
Correct?
Dr. Amy Vertrees (51:45):
And there's three months of dealing with complications. So this is what happens when my hands cause injury to somebody else. How do I continue to do this hard job? How do I manage myself? How do I protect myself [00:52:00] both mentally but also in my career? And then there's three months of power negotiating. So this is where I take my knowledge and my interactions with other people. I take my knowledge that I've learned about my strengths and weaknesses and how do I move the needle forward and things that matter to me. So how do I advocate for myself? How do I basically lion and tame the people around me? All the things that come up and how do I manage people around me and inspire them because we are really becoming the leaders and CEOs. And [00:52:30] then the next three months are the stop hating clinic because well can't get you to love it, but this is about how do you now run your practice like the CEO, we're trapped in employee mindset of the, I just do what I'm told or I do things within the constraints.
(52:48):
We don't really tap into the idea of vision and efficiency and aspiring other people and getting most of the people who work with us. And that is really what I learned as a private practice surgeon. [00:53:00] I've added another layer that's going to weave throughout this, which is really what young attendings need to know. Since I've had a lot of younger partners, I'm starting to see some of the things, new lessons that I've learned but didn't have much clarity on, which is how do you get other people to help you and also tell you, do you plan your clinic? How do you plan gaps in your career when you have a disruption in your career, whether it's an illness or a new family, how do you manage how you plan your career, and [00:53:30] how do you understand how you get paid? I just had that webinar, like I mentioned, called Math, not Drama, and the replay of that in bo surgery.com, and that's about how do we make the problems that we have, math problems that we can solve rather than the drama of irritation, resentment, annoying, things like that. So what I want to do is to give people more tools, how to approach this very hard job that we have in a way that makes us better, our patients better, and [00:54:00] the people around us better. Because in an interaction, you just need one person who feels safe and grounded. If you can be that person, you're going to transform the people around you.
Dr. Randy Lehman (54:11):
Yeah, I can see that being true in scenarios in my life. Thank you for sharing that. Real quick, for just a minute or two, could you give me a high level on how to get other people to help you when we're supposed to be the lone wolf? I thought,
Dr. Amy Vertrees (54:30):
[00:54:30] Well, it's basically we think about ourself and what we need. So the best way to get other people to help you is to understand they want to help you. They just don't know how. So the one thing that I learned as I'm going along is I have to make their jobs easier. If I have this idea that they want to help me, I need to make sure that I tell them all the things that I need. Like we were talking about in bleeding, the inguinal hernia. [00:55:00] If I have not said, Hey, I might need these things and I now ask for things, I make their job so much harder. They're going to get frustrated. I'm going to get frustrated. So all this has to do with stepping back and saying, I don't rely on a pref card. I tell people what I want directly and often until they get it.
(55:20):
I don't expect other people to do it. I don't expect the pref sheet to do it. I don't expect them to just know I know enough now about my case, the simple steps. So [00:55:30] I invite them to be part of the process. And so at the beginning of the case, when I tell 'em about something, I was like, I think this is going to be a straightforward inguinal hernia. I'm just going to need three fives. I'm going to need the five 30 camera. I'm going to need this mesh, have this available, have this available, have this available. It takes me five minutes. I don't rely on a pref card. They have it ready for me. They feel capable and strong and available. So when I need something like, oh, she said she might need that. That's how you get people to help you is that you have to be the one who is [00:56:00] controlling what is happening. And this is simple, easy. What typically happens is why don't they have that? This is their job. They're supposed to know that there's a magical unicorn pre sheet. So it's the things that,
Dr. Randy Lehman (56:13):
It's the same way I do it every time. It's on my card. I've been doing it the same way for five years. Why are you still handing me that?
Dr. Amy Vertrees (56:19):
I think what you do is you walk, that didn't work
Dr. Randy Lehman (56:21):
For me.
Dr. Amy Vertrees (56:23):
It can work if you have the same team. And also if we stomp our feet, they'll get it. But it's not inspiring people [00:56:30] and it's not making them want to help you.
Dr. Randy Lehman (56:32):
I've noticed something the places where I've been having the most fun and having the most success because I'm in multiple places now, right. I actually believe that the people around me want to help me.
Dr. Amy Vertrees (56:47):
Exactly.
Dr. Randy Lehman (56:48):
In the places where I am having the most success in the places where it still feels hard, truly. Especially the one, [00:57:00] I don't believe that they want to help me and I actually believe that. I don't think they want to help me. But the thing is, maybe that belief is the thing that's keeping it from being fun and everything, but I truly don't believe it. I think they're against me. So
Dr. Amy Vertrees (57:17):
One, I mean, you don't know if you're right or not, but it's certainly not helping you. So what I would offer is that isn't a thought that you offer yourself. That might be true. It might not be true, but it's certainly not serving you. So can we think of something [00:57:30] different?
Dr. Randy Lehman (57:31):
Right. Interesting. This is what coaching is all about to me is saying the crazy things that are the actual thoughts that go on in your head and you can change your thoughts. You don't have to, I'm not going to change that thought because I don't have to anymore because I'm not there. But it is actually something that you drive is your actual thoughts and sometimes the things that you believe you might be challenge yourself a little bit and say, [00:58:00] what if that's not true?
Dr. Amy Vertrees (58:02):
Yeah, exactly.
Dr. Randy Lehman (58:04):
Well, this has just been insanely valuable for an hour and a half, so thank you for all this time. We
Dr. Amy Vertrees (58:12):
Do have this problem. Right. It it's so much fun to talk to you that I think every time we sit down and talk, it's really long.
Dr. Randy Lehman (58:19):
It just goes this way. I mean, I could talk for another hour and a half, but we better call it, I might have to split this into two episodes. We'll see. Because there's just not a lot that I want to leave out. We [00:58:30] could simplify it a little bit, but I just appreciate you taking the time, everything that you're doing. I had one more question about your group. Is everybody in your group a general surgeon or just some kind of surgeon?
Dr. Amy Vertrees (58:43):
Just some kind of surgeon. I've got gyno, ortho, pediatric transplant, urology, general surgery, breast surgery, trauma. I may mention all kinds,
Dr. Randy Lehman (58:56):
But we're all wrestling with the same, basically problems running in [00:59:00] or and high stakes type of a case and high performers and whatnot. So that makes a lot of sense. Okay, wonderful. Well thank you so much Dr. Vertrees for joining the show. Really appreciate you having, I hope you actually come back some other time. So thanks for the time today.
Dr. Amy Vertrees (59:16):
Anytime. Thanks, Dr. Layman. So much fun talking to you.
Dr. Randy Lehman (59:19):
I hope you enjoyed this episode with Dr. Amy Re. She was fantastic and I really enjoyed the show. I appreciate you sticking around for the second of the two part series and we'll see you on the next episode of the Rural [00:59:30] American Surgeon.
