Episode 45

Nasty Gallbladders and Negotiating Contracts | Dr. Seung Gwon (Part 2)

Episode Transcript

Dr. Randy Lehman [00:00:11]: Welcome to The Rural American Surgeon. I'm your host, Dr. Randy Lehman, a general surgeon from Indiana. This show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics such as practical surgical tips, rural lifestyle, finance, training, practice models, and more.

We have a segment called Classic Rural Surgery Stories, where you'll get a feel for how practice in the country differs from the city. If rural surgery is your passion, this show is for you. So now that the Chloraprep has dried, let's make our incision. So you've given us several tips. What other tips did you want to share with the gallbladder? Like, when it's difficult, you said switch to the robot, dome down, trying to get the critical safety, putting a Ray-Tec in, suction, cautery, what else?

Dr. Seung Gwon [00:01:04]: Everyone should have a bailout procedure, you know, and the first thing I tell people is that early on, I thought the bailout was going open my first year. So I was like, oh, this was taught. Can't do it. And what I realized is it's not an easier surgery just because you're open. It's a different view. You see, you have a feeling that you have more control, but it doesn't necessarily make it easier.

Once I realized that, then my conversion rate was much lower. Right. And so what I tell people is it's okay to leave behind a cup of gallbladder. Typically, you want to leave a drain behind if it's safer for you to leave behind the cup of the gallbladder.

I always tell people it's better not to sew it over because then they're going to form new stones, even though you can do both the fender shading or the recovery constituting. But I believe if I'm going to do that, if I can see the cystic duct through the lumen, then I will put a little purse string around the cystic duct.

If I can't see it, I just leave the little cup of the gallbladder. I leave a drain behind, and then I talk to my GI, ask him to do an ERCP in the stent to try to direct the flow the other way. But sometimes it's okay to not do the whole operation the way we saw it, as long as you are safe and as long as you have the plan as to what you do after the fact.

I think in training, we did things to completion. We had our attendings, we had all this other help, and whatever they did, we finished it. And if they got into trouble, they corrected it. In a rural community or even in a community practice, sometimes you may not have all the ancillary support or even the additional surgeons that you need to do these bigger things. And so just make sure when you go in you sort of thought, well, if this happens, what am I going to do so that you can just keep on being efficient in your operation?

Dr. Randy Lehman [00:02:50]: Yeah, that's a great tip. I haven't done that yet, but then again, I haven't done it in Honduras. I mean, Honduras has the worst gallbladders that I've seen, but it's just something you got to have some bailout. Now when you go and try to do that, you're.

Another question I had sort of written down is how do you handle lost stones? So if you're going to do a finished trading fully system, obviously you're going to be dropping some stones. I have seen what the instrument I call a brontosaurus, it's a 10-millimeter stone picker-upper. It opens up like a.

So you like that one. Do you have any other tips for getting stones out?

Dr. Seung Gwon [00:03:26]: I always have my Ray-Tec in there and so if I know I'm going to open the gallbladder and sometimes if I've got like so much edema and tissue right around the neck and I decide to open up the gallbladder anyway, I will put the stones as I'm releasing them onto my Ray-Tec.

Then that makes it really easy. I wrap up the Ray-Tec like a taco and throw it into my, my, my same bag that I'm gonna pull out my gallbladder. But sometimes that'll help me direct the flow also because what I'll do is as I'll get into the gallbladder as I'm bringing it down, I'll actually open it up sometimes evacuate the stones and look and see where my cystic duct is and then see whether or not I can see where it's coming out from.

And then that helps me because I know where it's safe to dissect so that it lets me do a little bit more of my anterior dissection without me being afraid of like, I can't bluntly get through this tissue right now, it's so thick. But I know the cystic duct's back here, I can take this front part probably pretty easily.

Dr. Randy Lehman [00:04:18]: Yeah. One of my resident mentors told me there's no glory in a laparoscopic cholecystectomy. So it's. They're very hard sometimes cases. But even if you did it, it's like, oh ho hum.

The other thing that I do, we don't need to talk about this because I've talked about it many times on other shows is laparoscopic common bile duct exploration. I don't have GI and I don't have ERCP at my facility and I do routine cholangiograms. And the reason I do that is because we don't have that much volume.

And so I want my team to be able to do it when I need to do it. And then I have a choledochoscope that I and I have now successfully. It's, it's about once every four months or so clear the bile duct and they don't need the ERCP afterwards.

They had stones whether we knew it or didn't know it ahead of time. Sometimes I go knowing there's, there's common bile duct stones having imaging proving it. And this is my planned operation as a single-stage laparoscopic cholecystectomy with lap common bile duct exploration successful.

Then they don't require any transfer. But even when you do those cases, what's leading with is the no glory in the lap chole. The patient will come back and they'll be like, yeah, Dr. Lehman took my gallbladder out. They don't understand really how bad it was. And what you did is just say, oh yeah, took my gallbladder out.

Dr. Seung Gwon [00:05:34]: I used to and I tell everyone like I used to do routine cholangiograms for the exact same reason. I didn't want my staff to struggle when we actually had to do it. I found out I was the only one that was doing routine cholangiograms.

So about five years ago, I stopped doing the routine. Anyway, we finally got better GI support. We still don't have them on the weekends and in the evenings, and it just makes it quicker now for my team because we have a lot of turnover of staff and so you're constantly training the next new person and after a while, you're just like, okay, let me just make it as easy as possible.

Dr. Randy Lehman [00:06:06]: Yeah, two more questions for that. So I was going to ask you this earlier but how many cases, what is call for you? Like how many cases do you normally expect to do?

Dr. Seung Gwon [00:06:16]: It's variable. Down here we typically take one week of call at a time. So we each take a seven-day block. On a busy week, I'll probably do about 20 cases. On a non-busy week, probably average like maybe five or six.

I was on call three weeks ago and you know, did six on-call cases starting at 5 o'clock at night until they were all done. So it's sort of hit or miss. Yeah, the days of like operating all night which we thought would never happen again. After residency, I still probably get maybe like one time a month.

Dr. Randy Lehman [00:06:48]: Yeah. You said there are two main hospitals. Does the other hospital not have call?

Dr. Seung Gwon [00:06:53]: No, they have call too, so.

Dr. Randy Lehman [00:06:54]: But you're not in that call pool.

Dr. Seung Gwon [00:06:56]: No. When I first came here, I put myself on both call pools. I thought that was the best way to learn the PCPs and the ER physicians. I found it exhausting. So after about five years of doing that, and then both hospitals now had successfully been able to recruit additional surgeons, I decided to just take call at my main hospital.

Dr. Randy Lehman [00:07:14]: Could you be on call at both hospitals at the same time, or was that extra weeks?

Dr. Seung Gwon [00:07:20]: It was extra weeks. So it's. For us in general, we highly discourage. In this community because there's only.

There's two hospitals in this community that are about 15 miles apart. So it's not that it's hard, but if you are in the OR at the other hospital and an emergency comes in, unlike other places where there's somebody else you can call in, like down here on the weekends, all the other, like, the other surgeons are gone. They're on vacation. I'm literally the only one here, and there's one up at the other hospital. So sometimes if something comes in and they need help, we might call each other over to help each other out. But then we're like, we get our own emergency. We're like, okay, gotta go now. We got our own emergency. So I think it would be a little too risky because you might be in the wrong spot at the wrong time.

Dr. Randy Lehman [00:08:04]: What's the catchment area?

Dr. Seung Gwon [00:08:07]: Each of the towns in this county only has anywhere from, like, 6 to 15,000 people. My city is the county seat, and our city has about 50,000. If you took all 10 of the different cities in this county that are separated out from every other area by, like, you know, 150 miles or more, it's about 150,000. So what's interesting is we meet the criteria of rural for the state. We do not meet the criteria of rural for federal. But living here and working here, we're rural.

Dr. Randy Lehman [00:08:41]: Yeah, well, there's different types of rural. I mean, there's. And the quote I love, and I've said so many times, is you can either do carotids or C-sections, but not both. Yeah. So you're either in a rural place where you're doing really broad-spectrum general surgery, and if you wanted to, you could do pancreas or esophagus or liver or vascular, maybe, you know, or you're but you still have OBGYN and ortho and ENT and plastics and GI, maybe IR, or you're so rural that, like, you're. It's you and some family practice docs and that's it. And there's no OBGYN and none of that stuff. But then, of course, in those environments, you're not going to be doing carotids or esophagus or pancreas or things like that, which is where I've. I've chosen to be like, I'm talking. You're saying that the towns are so small, they're. They're between 6 and 15,000 or whatever. And my county is 12,000. The town is 1,500.

Dr. Seung Gwon [00:09:36]: Okay.

Dr. Randy Lehman [00:09:37]: But the other surrounding counties, they all sort of have their little county hospital. And three of the four don't have call at all anymore. Only one of them has call. And call for me, we take also a week at a time, is one to two cases per week. And it's usually like an esophageal food impaction. That'd be my number one most common case on call. We have probably two appies per month. Probably one or two emergency gallbladders, like, per month. But we're on call also for ovarian torsion and for esophageal food impaction, you know, so even more rural. But there's just a difference. Do you have IR?

Dr. Seung Gwon [00:10:21]: Intermittently? Some weeks we do, some weeks we don't. Some weeks we have it for one day. We never have it at night or weekends. It's very inconsistent. It's what I ask the hospital to please make it the highest priority. They're going through a recruitment phase right now. And I'm like, it really changes what we do because we get a lot of perforated diverticulitis and perforated appendicitis at nighttime. And if I don't have IR that can help me put a drain in, you know, and they're not responding to antibiotics, they all get a laparoscopic washout. I'm like, you know. And so I try to explain to the hospital, and they understand it. It's just radiology and anesthesia are two of the most difficult areas to recruit right now. There aren't enough of them, so we're looking. So if anyone knows, if anyone, send them our way.

Dr. Randy Lehman [00:11:04]: Right. Yeah, I mean, that's. And we transfer, for the most part, those patients, you know, and then that's a loss, too. But what is the name of the county that you're in? Imperial. And are you, is the other hospital as busy on call as your hospital is?

Dr. Seung Gwon [00:11:22]: They're a little less busy than we are. So when I used to take call up there, I wouldn't. My weeks at the El Centro hospital were much busier than my weeks at Pioneers, but it sort of is hit or miss. We find that the higher acuity cases a lot of times come to our hospital. So I see a lot of perforated diverticulitis, I see a lot of perforated appendix, I see these really horrible gallbladders. I see a lot of strangulated hernias where I've had to do bowel resections because they waited so long before they came in. And they're all morbidly obese with a BMI over 40. I just recently did a strangulated hernia on someone with a BMI of 60, and I was like, I hope we can extubate them. And he did great. But these are the things that typically come into a rural hospital where there aren't enough primary care providers, and the patients just wait a really long time, a lot of times until they're passing out from the pain before they come to the hospital.

Dr. Randy Lehman [00:12:12]: Yeah, I just quickly looked up Imperial counties. 179,000 total. The reason I'm diving into this so specifically is as I try to learn and be the expert and potentially be the consultant for rural hospitals and help nationally to keep rural hospitals open. Which I think a large part of doing that is to keep surgery close to home in the hospital, if we can, and how we can safely do that, how we can basically keep the surgeons out there and support them so that they can choose to do that. It's a very complex thing, but one thing is what is the need for emergency general surgery, since that's our topic, and I have heard that 1 out of 100 ER visits is going to need a surgical consult. And so then I'm thinking about that at some of my places where there's like 4,000 or 10,000 ER visits per year at the different locations. They're very low numbers. That's about as low of an ER as you can get is 4,000. Do we need 40 emergency cases a year? Yeah, but for us, we're doing about maybe 60 emergency cases a year, I would say, which, you know, like I said, about one a week, a little bit over. But we're doing this. The GI. You know, the GI bleeds, usually the GI bleeds that weren't really unstable, we still don't usually do because they're going to need ICU and we don't have it. But, you know, the GI bleed that wasn't, you know, we do a lot of those. And then the esophageal food impactions and stuff. So in your case, you got, you know, population 179. Do you know how many ER visits...

Dr. Seung Gwon [00:14:07]: Per year our hospital. So each hospital, both hospitals see about the same number of ER patients. Our ER volume is about 100 to 140 patients a day. That's how many patients come through the ER.

Dr. Randy Lehman [00:14:24]: Yeah. And so you're talking about 100 per day. So that's. That would be like 30 to 35 to probably 50, somewhere in that range. Thousand visits a year. And you said you're doing. You're thinking maybe between 5 and 20 per week. So like, say, 500 cases a year maybe.

Dr. Seung Gwon [00:14:47]: Yeah.

Dr. Randy Lehman [00:14:50]: So that's like one for every. Yeah, like 73 to 100. You know, it's. You're in that range of maybe 1 to 2% needing a consult. So you could, then, you know, we could go to a rural hospital who's trying to put general surgery services or whatever and say, like, you can kind of expect to capture 1 to 2% of your total ER volume. That's going to lead to a surgical emergency, basically. I just wanted to walk through the math, so appreciate you going down that with me. Very good. What other stuff do we... So in terms of taking the gallbladder out, we're back on that. You put it in a bag and you take it out that epigastric just slightly off midline. And is there anything else special? When you close up that port, do you close it or do you leave it open?

Dr. Seung Gwon [00:15:38]: Yeah, I close any port. So the rule of thumb is if it's 1 cm or larger, I close it. So the 12 millimeters, I close, and 10 millimeter trocars. If I'm using an 8 millimeter for the robot, but I'm doing a lot of torquing around it, then I will close those also. And then for me, because I'm superstitious, I close anything below any trocar that's been placed below the umbilicus.

I had one case of a Richter's hernia that I just wasn't expecting from an 8 millimeter trocar where the knuckle just got stuck in the trocar opening. So now, anything below, I'm just like Gravity Falls. I'm just going to close all those. Now, all I do is I close it with a suture passer. I use a wet suture passer. I don't like the cones and all those other things. So it just is a suture passer. I make sure I get a good fascia bite. I tend to do a figure of eight so that I get a really nice closure of it. And then I always inject that because that's the one where the patients are going to complain that it hurts because now you've got a suture. That's the fascia.

Dr. Randy Lehman [00:16:33]: Yeah, and I hate closing the suture passer through the rectus because I feel like you can create a, like a, even just if you're using a Vicryl for that.

Dr. Seung Gwon [00:16:43]: Yeah.

Dr. Randy Lehman [00:16:44]: Oh, Vicryl.

Dr. Seung Gwon [00:16:46]: Zero Vicryl, yes.

Dr. Randy Lehman [00:16:47]: So even if it's a Vicryl, it's going to go away. To me, I'm thinking I'm going to take my anterior fascia and stitch it to my posterior fascia. And the muscle is going to be split in that area. And even after it scars down, it's going to constantly have a scar there. So first off, I don't use any 8s because I don't have a robot. So it's either a Hassan or a 5 for me. And in residency, and again, I'm not saying what I do is right or wrong. I'm just having a conversation here. So 5s are free, was the quote from residency. So if you need it, put it.

The only time I put an off-midline 12 is when I'm doing it intentionally and when I'm doing hiatal hernias; I put it in the left upper quadrant. And so what I've moved to do, because I used to stitch those either with a suture passer or, you know, I'm going to stitch them up and open, and I'm thinking about how to do it. And I would put sometimes the stay stitches. What I've moved to doing is I just stitch the anterior fascia closed because I don't want to close it to that posterior fascia. Then technically, I'm leaving that posterior fascia and peritoneum and everything open, but hoping I don't get a Richter's hernia, I guess. You know, but there's nothing for it to push up against.

Dr. Seung Gwon [00:18:10]: Sure.

Dr. Randy Lehman [00:18:10]: And so tell me how I'm thinking about that wrong.

Dr. Seung Gwon [00:18:15]: I guess. So it's not wrong; it's how you do it, right? So one of the societies that I'm a part of and I try to go to the conference, if not every year, at least every other year, is the American Hernia Society. It is fascinating. I actually like to go to specialty conferences because now you have everyone who does just that talking about just that. So I feel you get a lot of information. I like going to the American Breast Society conferences.

After going to them, and maybe I drank the Kool-Aid, I don't know, but after listening to how they talk about where you're making your holes and why, and as they look at the incidence of hernias and hernia recurrences, and re-recurrences and how it all starts. Knowing that we're not the only ones who get in the belly, you've got your urologist, you've got your OB-GYN guy, you've got all these other specialties who also go in the belly. And they're not going to these hernia conferences because we're the only ones that fix the hernia, despite who puts a hole in there.

The idea that most of the holes that you make in the midline will ultimately become either a nidus for a hernia or start becoming a hernia. Once that starts, you might get, in a thin, healthy patient, a repair that lasts them their entire life. The reality is the majority of them will come back requiring additional repairs, each one getting subsequently more difficult. So my thinking, and it's funny because it's not just me; independently, like a lot of the other general surgeons in my community, we really avoid putting anything in the midline. As a result, we realize it hurts more going through the muscle, exactly what you're saying. You are fusing the anterior and posterior together when you're doing that in the middle of the rectus.

But you're also less likely to get a hernia because of all the supporting musculature around that area. Just the other day, I got called into the operating room—not operator, I got called for a consult for someone who had had a laparoscopic surgery by a gynecologist a month ago and already had formed a hernia at the epigastric site where they had put one of their trocars. It wasn't a difficult surgery, but now I had to take the patient back to the operating room to pull out the momentum and close the hole.

Dr. Randy Lehman [00:20:19]: But that's a dehiscence really, not a hernia.

Dr. Seung Gwon [00:20:21]: Really, truly, yeah. But part of it was he didn't close it because he thought it was small enough, you know. And so I feel like avoiding the midline where we think it's free because we're like, oh, there's nothing else, there's fascia. But realizing that that fascia should be really respected a lot more than I have in the past, that's what's really changed my thinking. What I realized in medicine, in general, is certain things go in a straight line, but most things go back and forth in a pendulum. Perfect example is, you know, how to handle reflux disease between medicine and surgery. It goes back and forth, seemingly every 10 years, as far as the recommendation.

So I think right now, as we see obesity increase and we see hernias increase, that now the Hernia Society and hernia experts are trying to create new dogma about how to treat the midline. Who knows, you know, 20 years from now, whether or not that will still be... I won't be practicing at that point.

Dr. Randy Lehman [00:21:14]: Right. Yeah. I would like to ask you just a couple. I love tricks and tips and slick moves and things like that. So I was always on the lookout for that and writing them down in a notebook through residency. I was just wondering, do you have any slick tips or tricks kind of like you described for us for gallbladder, for appendix, or for anything else, acute care abdominal? Like, for example, small bowel obstruction or anything like that?

Dr. Seung Gwon [00:21:42]: Huh. I should have been prepared for this question.

Dr. Randy Lehman [00:21:44]: I have one. You could think for a second on the app, and I may say it and you'll say, never do that, and that's fine. But the trick for me for an appendectomy is once you identify the base and first off, always take the base first and don't mess with the mesentery is what I do. I mean, I know other people just chomp down with the harmonic and they take the mesentery with the harmonic, and then they're left with it and then staple it off. But that's not the way I do it. I take both with the staple load for the most part, and I get the base.

Then when I get my Maryland, it's what I'm using all the way through, I leave it there or I'll kind of hold the appendix and stretch it up and down parallel to the vessels. Then I get my second instrument alongside, parallel to my Maryland, and do an anterior-posterior spread. That solves all the fussing and makes it so easy for me to get my staple load. Then, of course, I bring the thin load in down, and it is virtually always easy.

Speaker A: Folks have criticized me for doing that, saying that you'll get into bleeding. It's when you go parallel to the vessels. It hasn't really been much of a problem for me. So that's like a maybe not everybody knows it trick that I could share. Do you have anything else like that? Or if you don't, that's fine.

Dr. Seung Gwon [00:23:03]: Yeah. Okay, so there's an instrument that I brought down to my community that I had used in residency, and I thought it was something that everyone used, and no one down here had seen it before. After I brought it down here, within months, I had to ask them to buy a couple of other ones because they kept disappearing. It's called a laparoscopic finger. I don't know if you have ever seen it.

So it's this long instrument, and on the end, it almost looks like a curved spatula that you can do this with. So if you're doing straight LAP, and especially if you've got adhesions and you don't want to sit there with a, you know, a peanut or Kittner, or you don't want to use a Ray-Tec, it allows you to bluntly do this with it. Versus striking through has saved my butt multiple times in a perforated diverticulitis and trying to get those adhesions off the pelvis, trying to get to where the ureter is. It's called the laparoscopic finger.

If you don't have one, they always know where it is. Half the time, especially when you're at the pelvic sidewall and trying to get the adhesions off the side, or if there's just a bunch of gunk in there, it lets you just go through like your finger would and just sort of push things around without throwing a lot of other stuff in there. So that's probably the tool that a lot of people didn't know about that I thought everyone did.

The other thing I would say with that is, I think it's sort of interesting. One of the things that I appreciate is—and again, I think it's because in training, all my attendings did things in such different ways—that I always tell everyone, do it the way you want to and you're comfortable doing, but know the other way to do it. I actually do my app, however it presents to myself. If it presents where the appendix is sitting straight up and I see the mesentery, I use a harmonic, take down the mesentery to the base.

If it's retrocecal and it's a mess, I do exactly what you do. I dissect off where the base is first, I leave the mesentery alone, I find my window and staple across, and then go backwards. I think that the key is always know a different way to do it in case the way that you want to do it every single time isn't going to work that one time. That gives you a little bit of comfort too, where you're not sitting there going, oh my gosh, what the heck do I do next? Because that can get a little bit, you know, scary when you're in the OR.

Dr. Randy Lehman [00:25:02]: Yeah, I love it. Well, we're, I'm being long-winded, and I really appreciate this is an incredible opportunity. I just appreciate all your time doing this. But we probably, for the sake of time, should move on to the financial corner. If you had a money tip for our listener, we'd love to hear it.

Dr. Seung Gwon [00:25:20]: A couple of things, actually. The first thing, and it's not necessarily a money tip, but it sort of is. Everyone should get disability insurance, but they should specify own occupation. I didn't understand how many people don't get counseled on that when they graduate med school and go into residency. The difference between own occupation versus regular disability versus, I actually met someone recently who had no disability because they had never been counseled.

I know, right? You spent literally over a quarter million dollars to train here. Then you don't have a backup plan. Own disability means that if you can't—so as a general surgeon, if I can't do general surgery, it doesn't matter that I can go do a job doing wound care or utilization review. My disability pays me out for the fact that I can't do general surgery. I can still use my brain and my knowledge and my experience to do something else in medicine, but the thing that I've been trained highly to do, you're still going to get your disability for that. It costs more to get it that way, but I highly recommend it. It's so worth it if anything were to happen to you. So that's number one: be very specific about the type of disability, how.

Dr. Randy Lehman [00:26:21]: Do you know when you don't need insurance anymore? Like for example, if you're 62 and you're retired, you could retire. You have enough financially to retire, and you're still healthy and you still like your job and you still like working, would you recommend for that person to have disability insurance? I would probably not. I would probably cancel it at that point.

Dr. Seung Gwon [00:26:44]: I would cancel it. I would say that when you're at the point where if you're working because you enjoy it, not because you need to pay the bills, and if you were to retire right now, you could live off what you already have saved. I think that's the perfect time to get rid of disability.

Dr. Randy Lehman [00:26:59]: And a lot of the disability policies only pay till 65. Right. So you may find yourself in that situation at 54. You could retire, you're good, you know, and then they're making money off your policy. Right. So the chances are that you're not going to get the, quote I love is, you only insure against something that would be a financial catastrophe. That's why you don't buy the insurance on your TV, you know, because if it, you know, who cares? But if you're super in debt and you, you know, you've over-leveraged on your car and you're losing your car, like I don't have a liability. I have only a liability policy on my car. I don't have full coverage. Right. Because it wouldn't be a financial catastrophe if I totaled my car. I'd just buy, you know, another one.

Dr. Seung Gwon [00:27:38]: Exactly, exactly. So that would be one. The second thing, you know, it's sort of interesting. Everyone will have their idea of how best to start out. So I had one friend from medical school who, right after residency, he moved in with his parents for three years, paid no rent, didn't take a single vacation, didn't buy a car, and literally paid off all his loans in three years. Now he has a house, a car, a plane. I mean, so he has all his money because he didn't have to pay all the interest payments.

There's no way I could ever get back home with my parents, so that was just not an option for me. Other people will tell you, don't make your first big purchase because you're going to have, and I'm sure everyone on your program has said this, we literally go from getting paid fast food worker wages as a resident to getting paid more money than we've seen before unless we had really, really wealthy parents. And so sometimes that's dizzying. It's like, what do you do with it all, right? Then you come back to earth; you realize you still have to pay your med school loans, you still have to pay your disability insurance, you still have to pay your malpractice insurance, and things start adding up.

The thing I tell people is, whether you are a saver or a spender, whether or not you're looking to enjoy it now or save it to make sure you have to enjoy it later, make a budget. I was so surprised at how many physicians are like, I've got this money, and they don't really look and see what you need and what you should put away and put in a high-risk investment because you have time, what you should put away for your pension plan, because we don't, unless you're a W-2 employee, have a retirement plan. And most of us aren't going to be able to survive our lifestyles and social security when we're done. So it's budget out what you think you need, and no judgment.

If you really need that Porsche, I'm not going to tell you not to buy it. I'm just going to tell you that you're not going to get other things if you pay for that. If you could, you know, maybe get a Hyundai instead, you're probably going to have a little extra money. I don't like to tell people how they should do it based on what I and other people know because we're all going to do it differently. I'm sure all of us have had advice from someone telling us to do something, and we didn't follow all of it.

One thing that was important to me was that, due to attending a really expensive med school, I used a bulk of my relocation, signing bonus, and loan repayment bonus to make a huge bulk payment on my loans. After I made the bulk payment, I decided to take 20 years to pay it off, acknowledging it will be a lot. But I love to travel, and if I hadn't budgeted for travel, I'd just be in a job I love but would be miserable when not working. I really do think that work-life integration at some level is really important. However, if you spend a little less at first and then realize what you need to maintain and sustain, I think that makes sense. Maybe wait six months before making any huge purchases to see what is sustainable and comfortable. As physicians, it surprises me that some literally live paycheck to paycheck, and that's a little sad to me.

Dr. Randy Lehman [00:30:33]: Yeah, you can have anything you want. You just can't have everything you want.

Dr. Seung Gwon [00:30:37]: Yes.

Dr. Randy Lehman [00:30:38]: And work-life integration—I like that word. So thank you. Do you have a personal surgery story that is just classic rural surgery that you'd like to discuss?

Dr. Seung Gwon [00:30:48]: Oh, absolutely. I thought about this one, and then it came two weeks ago. I was like, yeah, this is definitely the one. In a rural community, many patients don't see their doctors regularly. In my community, we have a lot of diabetes, obesity, and comorbid conditions. Many people don't take care of their hernias by informing their primary care provider or getting referred to a surgeon. So, I see a lot of incarcerated hernias, which I either manually reduce while monitoring them or require operating because they can't reduce it.

A patient came in with a BMI of 60, and I thought, how? Then they said he was really short. He had an inguinal, scrotal hernia that was visibly hanging down two-thirds of his leg. The ER doctor had tried reducing it with fentanyl and morphine, and he was in pain, very tender. I attempted reduction, hearing the gurgling of the bowel; I managed to reduce half before it got stuck, so we prepared for the operating room. We used the robot because if a bowel resection was necessary, I preferred trying laparoscopically.

Once in the operating room, with assistance from my scrub tech, we reduced the scrotal component, seeing that it was all purple. I started dissection, thinking I can't put a mesh if the tissue doesn't revive, but if it does, I can proceed. After about 30-40 minutes, the tissue, initially all purple, appeared pink and patchy, suggesting viability. There was no need for a bowel resection, as it had only recently become severely incarcerated. I completed a formal hernia repair, washed out the belly, and kept him on antibiotics. He recovered well and went home.

Dr. Randy Lehman [00:33:20]: Wow, that's incredible.

Dr. Seung Gwon [00:33:22]: There are times I haven’t been so lucky, and situations call for a bowel resection. In those cases, I ensure I put a purse string around the peritoneum and omentum near the hernia. I don't do a formal repair, avoiding tissue plane violation, but I avoid a large gap that could re-incarcerate the bowel. I offer follow-up repairs to patients, and some intend to return only when necessary.

Dr. Randy Lehman [00:34:07]: Oh, man. They don’t know. But that’s all right. If you do those repairs subsequently, would you use the robot?

Dr. Seung Gwon [00:34:17]: I do. I learned straight laparoscopic transabdominal preperitoneal repair in residency. That was my practice for six years in this community before acquiring a robot. It's simpler and quicker now, and so I do all my TAP repairs with the robot.

Dr. Randy Lehman [00:34:36]: Yeah, I do a TAP as well, straight-stick. But then, for recurrence or bilateral, I do laparoscopic. Otherwise, mostly open for unilateral on a man, but I do TAP on women. When requests for a laparoscopic approach arise, I fulfill those as well.

Dr. Seung Gwon [00:34:59]: I still perform open repairs. Recently, a patient with a prior open left requested the same on the right. It's valuable for general surgeons to adapt their approach fittingly. With prostate cancer history involving radiation, I would inevitable choose open repairs due to scar tissue complexities.

Dr. Randy Lehman [00:35:21]: Let me ask you a question. Have you ever heard of somebody doing an open inguinal hernia repair and then immediately placing ports and doing a laparoscopic repair in a sandwich technique?

Dr. Seung Gwon [00:35:37]: No. I've observed switching from laparoscopic to open, then back again, but never starting open and switching to laparoscopic. When starting laparoscopic, getting stuck, why not complete open? No judgment there, but never seen the opposite. For the peritoneal with ports, I suppose they're trying for sac reduction or minimizing adhesion.

Dr. Randy Lehman [00:36:01]: Let me give you the scenario. It would be like a patient is elected for an elective large inguinoscrotal hernia.

Dr. Seung Gwon [00:36:09]: Okay.

Dr. Randy Lehman [00:36:09]: And the pre-op note says, because it's so big, I'm going to do surgery open, fix it, put the mesh open, but still to reinforce it, go in laparoscopically and do a whole laparoscopic repair and put a piece of mesh inside.

Dr. Seung Gwon [00:36:30]: The prepared mesh and then they have an onlay mesh. Yes.

Dr. Randy Lehman [00:36:35]: Two pieces of mesh? Yes.

Dr. Seung Gwon [00:36:36]: Never. I've never heard of that.

Dr. Randy Lehman [00:36:37]: Yeah, me neither.

Dr. Seung Gwon [00:36:42]: I'd be curious, like, if that was something that they adopted or someone actually is training people to do it that way. No, I've never heard of that before.

Dr. Randy Lehman [00:36:50]: I think it's made up.

Dr. Seung Gwon [00:36:52]: Okay, all right.

Dr. Randy Lehman [00:36:53]: Very good. Resources for the busy rural surgeon. As the last segment before we get out of here, did you have anything that the rural surgeon should just for sure know about?

Dr. Seung Gwon [00:37:01]: Two things. The advice I give to rural surgeons, the people who do the first thing is I think it's important to go to conferences because it's very easy to get isolated, and that's one way to network, but also to make sure that what you're doing is still standard of care.

So I do think that it's very easy to stop going to conferences. You're busy, you don't have. It costs money. It's time away from a practice. But I think that's really important. But for me, with online and social media, I actually get a lot of benefit. And I wrote the names down for two groups in particular.

One is for people who do hernias. The International Hernia Collaboration is phenomenal. It's a Facebook group. It is multi-country, not just the U.S. All the great hernia leaders, you know, everyone from Todd Hennifer to Yuri Davitsky to Dias there, you know, David Chen, they're all on there. And they are not only showing video, what they do, they are very, very generous in their feedback.

And the whole hernia community and all the surgeons that are on it, you can post your video and show people or ask questions about things, and then people contribute. And sometimes you like all the contributions and sometimes there's arguments on there, but it's a way. I tend to be a lurker. I've never posted a video, but I will frequently go through there, especially if I'm going to do a hernia, to sort of see what people are saying and doing and seeing if there's any tips or tricks that they have. So I think that's really helpful.

There's another one that's for women only, but it's called Women in Oral Surgery. And it's also a group on Facebook. And so sometimes I'll go on there, and again, people will talk about interesting cases that they've seen or, you know, they'll ask the question like, hey, I'm about to do this. Any concepts and thoughts. And I find that's a way to make your networking even broader.

These are not necessarily people you know personally. You're going to get a full range. Right. Just like with anything, you have people who are phenomenal and experts in the field and people really like, maybe we don't want to do that, but it gives you exposure to what a lot of people are doing and thinking and seeing.

And I think that being a rural surgeon, you need to know where to look. Whether you know what on YouTube, you're going to go look for your videos. Because, like, for example, there's a huge controversy right now with people who do very advanced techniques for abdominal wall reconstruction, especially like the robotars and the ETAP procedures. There was a huge New York Times article, Cleveland Clinic was involved. A lot of the hernia people got really upset with it.

And the thing you see is if you don't know what's good or bad and you just go on like YouTube or go on some random site, you may be learning things that maybe shouldn't be done. And so I feel like going through these curated sites, whether it's the ACs or Sages, because I know they also have their channels and they put a lot of content from the conferences on there, I think that's a really great, great resource for people who aren't doing it in these big areas where you have tons of mentors and research going on around.

Dr. Randy Lehman [00:39:52]: Right? Yeah, I love it. Well, that is very helpful. Thank you so much for those specific tips and mostly for coming on the show and taking your time to just share the experience that you've had with our listener. So I really appreciate it.

Dr. Seung Gwon [00:40:06]: Thank you so much for having me. And your stories are incredible. You know, it's funny, not that I never thought that this is what I wanted to do. So definitely wasn't one of those people that was like, hey, I definitely want to go and do oral surgery. But it was sort of interesting because I knew I always wanted to do medical mission work.

And so what I loved especially now that, you know, I'm meeting people who want to do rural surgery and I'm talking to people because I've been doing it for so long now. I find it. It's fascinating and it's also really uplifting. I find I learn, even 20 years out, I still learn so much from talking to other people. So this has been such a pleasure for me.

Dr. Randy Lehman [00:40:42]: Yeah. Well, thank you very much. We appreciate it for sure. And thank you also to the listener for joining us for this episode of The Rural American Surgeon. We will see you on the next episode.