Episode 72
What Does a Rural Surgeon Actually Need to Know?
Episode Transcript
Dr. Randy Lehman (00:31):
Welcome back listener to the Rural American Surgeon podcast. I'm your host Dr. Andy Layman I have with me today Dr. Amiri, the professor of surgery and program director at Marshall University. And David, uh help me out.
David Kenarowski (00:44):
Kenarowski
Dr. Randy Lehman (00:45):
Gennaro asked you for a fourth year, uh resident, am I right or did you just start your fifth year?
David Kenarowski (00:50):
No, I just started four.
Dr. Randy Lehman (00:52):
Okay, just started for um who are going to talk to us about the rural surgery training that's going on at Marshall and um I just appreciate you guys taking the time to join us and share with the listener about your program.
Dr. Amiri (01:04):
Thank you for having us.
David Kenarowski (01:06):
So thank you.
Dr. Randy Lehman (01:07):
So, yeah, thank you. So, um to start, um your program's pretty new, right? And so just tell me a brief overview, how did it come to be? why does it exist and what are your goals with the program?
Dr. Amiri (01:21):
Sure. So, uh, we are in our fourth matched class. Uh, David's our most senior resident. Uh, and uh, we started this probably about five, six years ago as, uh, you know, the the motto of the med school was to train rural physicians. And we've had a very successful run of training general surgery residents here at the main program. Uh, and the thought was, you know, why can't we expand on that and train more surgeons to be rural centric? Train them to do specialties outside the realm of general surgery so they're better prepared to be a well-rounded rural surgeon. So, that was kind of the vision.
Dr. Amiri (02:00):
the dean and the DIO had the same vision as we did, so we went full force. And here we are.
Dr. Randy Lehman (02:08):
Yeah, and so, um, what, how's it, I guess maybe we can just go to David and say, uh, how do you feel like you feel like your training is meeting those missions and those goals and then and what are you looking forward to in the next two years? Um, we'll start start with that and then and then I'd like to talk to you about your career plans as well.
David Kenarowski (02:25):
Sure Of course.
David Kenarowski (02:27):
Um, yeah, I think definitely, um, meeting those goals, we spend as part of our curriculum greater than 50% of our time focused in a rural setting. Um, we have a couple of outlying community hospitals where we spend that time and so in that setting we're faced with, uh, you know, challenges of course of limited resources and, um, you know, having to make those kind of triage decisions as far as which patients you can manage there and which patients need to be transferred. Also, um, seeing a broad scope of of general surgery as well as some subspecialty things like, uh, C-sections for example.
David Kenarowski (03:06):
I've scrubbed probably about twenty C-sections now.
Dr. Randy Lehman (03:09):
Have you started to look at uh jobs or do you know where you're planning to practice?
David Kenarowski (03:14):
Oh, just kind of looking all over the country really, just uh looking for a good rural hospital to to go to.
Dr. Randy Lehman (03:20):
Heh. Yeah. Are you from West Virginia?
David Kenarowski (03:23):
I'm not. I'm originally from Northern California. I grew up near Yosemite National Park, up in the mountains. In uh little town up there about 2,000 people. And uh so I come from a real small town and looking to hopefully end up in a small town.
Dr. Randy Lehman (03:39):
Yeah, perfect.
Dr. Randy Lehman (03:40):
So, you know, you look on a map and Marshall Huntington, West Virginia and Marshall University is like tucked in the corner of Kentucky, Ohio, West Virginia, squeezed along the river and the, I guess that's the Ohio River, right? You know, obviously rural surgery is not the same anywhere. So, I'm operating at the hospital I was born at in northwest Indiana, but when we have cities of 200,000, 45 minutes each direction with good interstate, you know, to get there. And then you compare that to where you're at or or places out west that are very rural and remote.
Dr. Randy Lehman (04:16):
And so you might find yourself in a place that that has an ICU and has um sort of sub-specialists around you, but you're still really isolated because like everything general surgery falls on you. So you're doing those bigger things in general surgery, maybe it's the trauma and then also the the esophageal and the pancreatic and liver pathology. Or you might find yourself in more of like a smaller hospital setting where yeah, you have to stabilize things, but your day-to-day practice um might include more of endoscopy, maybe C-sections.
Dr. Randy Lehman (04:52):
um maybe you don't have certain things like ortho urology OB/GYN ENT plastics and then you might be called on to do some of that stuff whether it's um you know cerks and vasectomies and hysterectomies and tubals and and c sections. Um the next question I had is do you guys have a sort of um flexibility in your program to be able to tr- like once a person identifies in in their training the place that they're going to go is there some flexibility to be able to chase down some of that subspecialty stuff should they need it in their later years?
Dr. Amiri (05:27):
Yeah, I think we're still growing as a program as far as what requirements in subspecialties outside of general surgery we'd want the residents to have, like a base knowledge. Um, for example, as David alluded to, he's done like 20 C-sections. Um, I don't know what the magic number is. I think he's about right where he needs to be for those. But I mean, he's already told me that he'd like to do more advanced endoscopy procedures, something we don't currently have a curriculum for, like ERCP. So I'm trying to find the right pathway or avenue to help him get those trainings. I do also find that some residents kind of know where they want to be career-wise or where they want to practice.
Dr. Amiri (06:07):
Um, so, you know, figuring out where you're going to land first and then figure out what resources or what things you need to focus on will probably be the next step for him and his counterpart. Um, he may want to do more vasectomies because he's going to be the guy to do it. Or he might go to a hospital that has no IR, so he's going to have to work with the IR guys the one day a week they come to the rural hospital and start learning how to do needle aspirated drains. Um, which is the reality of his training program.
Dr. Randy Lehman (06:37):
Yeah. To clarify, you're a dedicated rural resident in a program that has sort of traditional general surgery that has existed for a while, right?
Dr. Amiri (06:48):
So actually we are two different residency programs in Marshall.
Dr. Randy Lehman (06:51):
C
Dr. Amiri (06:52):
One is the traditional five-year general surgery residency program as it's always stood, and that's where I trained. And the rural program is a separate ACGME-accredited program where we have three of our own residents per year and they rotate in and out of Huntington, but two-thirds of their time are at the rural hospitals.
Dr. Randy Lehman (07:10):
Okay. Do the same like grand rounds and you have the same program director.
Dr. Amiri (07:14):
No, different program director, same didactic schedule.
Dr. Randy Lehman (07:18):
Okay. Got it. And then how did how did you guys make that decision to structure it like that?
Dr. Amiri (07:24):
Uh, I think it had something to do with the ACGME offering a rural designated track or a separate residency at the time. I think nowadays they're starting to make just tracks where you are part of the general program but you're one the one resident that goes more rural than the rest. At the time we applied, I think it was a separate residency program only offered.
Dr. Randy Lehman (07:45):
Yeah, that makes sense. All right. So if you think of the kind of applicant that you would be looking for that would do well in your program, what are some of the traits that that applicant would have?
Dr. Amiri (07:58):
So, I would say one, a person that's probably not looking for a fellowship, to be honest, right? If they're going to want to go into pediatric surgery. I mean, it's going to be very difficult first to get into pediatric surgery from a residency like this, but same time I'm training people to go back into the workforce and be a well-rounded general surgeon. I also look at people's hobbies, what they're into, right? Are they outdoorsy people? Are they into hobbies that are not requiring a major city center? Where they came from, you know, I read their personal statements. You know, did I come from a small town, want to go back to a small town? I read that a lot and I'm attracted to those type of applicants.
Dr. Amiri (08:38):
And then I also want to know, you know, what hobbies they have as far as burnout mitigation, right? You got to have to be able to manage being in a, you know, quieter setting and how to occupy your time so you don't burn out.
Dr. Randy Lehman (08:52):
Yep, makes sense. How many cases are are you guys able to crank out at that program? Like you feel like volume's going to be higher for the rural uh graduate because of some of their experiences or is it kind of about the same?
Dr. Amiri (09:04):
David, you can answer that.
David Kenarowski (09:05):
Yeah, I think probably uh about the same, maybe slightly higher. Um, we we do stay pretty darn busy and one of the one of the nice things about our arrangement is that when we do spend time in the rural setting, there are no other residents there at all to compete with, you know. So we get a lot of access to cases and also are able to get started in the OR very, very early on, even in the intern year. Uh, we're getting people in the in the ORs and scrubbing on cases. Uh, yeah, I think good case numbers and and uh a lot of early experience.
Dr. Randy Lehman (09:41):
How many other other sites do you go to?
David Kenarowski (09:44):
There are two other sites outside of Huntington that we that we travel to.
Dr. Randy Lehman (09:48):
and you're spending two-thirds roughly of your time there.
David Kenarowski (09:52):
Correct. Yeah, yeah, roughly a third.
Dr. Randy Lehman (09:54):
fifty to two thirty Okay, got it. Yeah. Um, and so you take call when you're out there? Yep. Is that like pretty much always on call, never on call kind of thing or... or how does it, is it dedicated time?
David Kenarowski (10:07):
So, we do like Q2 or Q3, but the as you know, you know in the rule setting the the call shifts are not nearly as demanding as they are in, you know, the big cities. Um, and so, you know, might get, you know, maybe two or three calls to the ER or something, uh, or consults, you know, but not overwhelming. Um, it is pretty unusual that we'll take a case in the middle of the night, but you know, obviously sometimes that happens. Uh, and we'll do, you know, home call, um, when we're at the rule setting where we can, uh, you know, rest there while we're we're not needed.
Dr. Randy Lehman (10:43):
Um, is the housing provided by the program?
David Kenarowski (10:46):
The program has worked out housing for us, yeah, that's that's been a big big push. Uh we asked for that as residents and the the program has really helped make that happen. It it took a little while to get there, but it uh we we now have uh apartments and places to stay at at each of the sites.
Dr. Randy Lehman (11:03):
Yeah Is it big enough for a family?
David Kenarowski (11:06):
Um, at one of the sites not uh big enough for a family. At the one of the other sites, yes, but things are still under development on that end too.
Dr. Randy Lehman (11:17):
Yeah How far away are these secondary sites from Huntington?
David Kenarowski (11:21):
uh one is about an hour and the other one is about an hour and a half.
Dr. Randy Lehman (11:26):
Okay What towns are they?
David Kenarowski (11:27):
uh the towns are in West Virginia is Logan, West Virginia. So coal mining town and then um the other direction is uh Gallipolis, Ohio. Is the other town.
Dr. Randy Lehman (11:41):
Yeah and people can look it up themselves if they'd like to on the map, you know. Uh, that's That's perfect. And um when you're out there at the other sites, do you spend time with specialists, subspecialists as well? Like have you done many cases with like ortho, ENT, urology?
David Kenarowski (11:56):
Yeah, um not so much urology that hasn't been available as much as I'd like. Um but we did just get a new urologist at Logan, so hopefully be able to do some more work with him. Um.
David Kenarowski (12:10):
but definitely a lot of opportunity uh to work side by side with the uh Ob/Gyn attendings. Uh and they're always very grateful for our our assistance and you know, and everything in the OR. There's oftentimes they'll call for us. They'll say, "Hey, is there a resident available to come, you know, help scrub this C-section?" you know, so. Um so that'll happen often. Um and then uh there is ortho at both the sites. Um and and they're more than welcome to have us come and work with them. I've logged about ten carpal tunnels, you know, because I thought it might be something I'll do.
David Kenarowski (12:44):
I haven't bothered with like doing like, you know, femur nails and stuff like that because I don't know that I really need to do that. I've scrubbed a couple of them, but I don't know if there's a lot of utility in that out there.
Dr. Randy Lehman (12:56):
Yeah, I so I'll maybe put my two cents in because I'm out six years and I trained Mayo Clinic rural surgery track and so I didn't know what the value was at the time of my training of each of the individual things. So, you know, on your absite, you know, parotid shows up just as commonly as, you know, C-section does or endoscopy related things. So, the question is, how common are you actually going to see this? Well, I I have been able to have a pretty good volume of carpal tunnel. That seems it seemed pretty easy. First off, most patients need two of them.
Dr. Randy Lehman (13:35):
so you can double it whenever you but um you know like parotid I seriously I mean I rotated with ENT and I thought yeah I could do superficial parotidectomy and obviously you know it's on the test and it can show up on your oral boards and everything but there's no way at this point that I would ever consider doing that because you know zero cases in six years it's a one in a hundred thousand diagnosis and most of the time they're not going to find you because referral patterns are somewhere else so what I've found is endoscopy is probably the number one most valuable thing that you can bring as a rural surgeon with or without ERCP but it's great to be able to handle the bile duct at least one direction so if you can learn laparoscopic common bile duct exploration that's pretty sweet
Dr. Randy Lehman (14:14):
And that's what I do and I don't do ERCP and then, you know, I, you know, step on people's toes when you start doing ERCP, but everybody's happy for you to do lap com and bowel like exploration. It's like totally your thing.
Dr. Randy Lehman (14:25):
there's that and then second after endoscopies probably C-sections, but it's obviously variable. So like all the hospitals I'm working at in Indiana now don't have an OB department, so C-sections, but but the places that do still offer it, it is a big value and it's a huge need and if one source for proof of this is I have done a little bit of locums work with a locums company and I mean the lady I'm talking to said she's got like two or three people that do C-sections total that do general surgery and C-sections and these places are trying to cover general surgery and C-section call, it's like a double value.
Dr. Randy Lehman (15:06):
and honestly pay is can be great. You you should expect and demand quite a lot more pay if you're doing C-section call, in my opinion. And so I think you're on the right track. I mean you're you're saying exactly it's like, and I think it's great to operate on a few hips and a few total joints to kind of like know and then know where your limit is. You know, okay, I'm not going to put in plates and screws, and that's where I'm going to draw my line. Or or you are. Like I have a mentor who obviously would pin a hip on a nursing home patient who would fall and and uh there's no ortho around and transport's a big deal and they're bedridden to begin with. Like that's different than trying to do elective knees and hips.
Dr. Randy Lehman (15:45):
Um, and by the end of your training, you'll kind of know what's right, and in your community you'll know, you know, what the right thing is to do. So, it's my two cents on that. What are you thinking? Any other thoughts to add to that?
Dr. Amiri (15:56):
I couldn't agree more with your sentiments.
Dr. Randy Lehman (15:58):
So, what are the main things that you would like the listener, assuming that the listener is a person considering going to your program, uh to know about your programs? Like, don't come here if you're expecting this or uh, you know, we're looking for this kind of a thing. Open-ended.
Dr. Amiri (16:15):
Do you want to go first, David?
David Kenarowski (16:16):
Well, I I would dovetail kind of off what you said there. Like we're we're definitely looking for somebody that has that rural mindset, you know. Um, and occasionally we'll get an applicant I think where they would consider us a backup program and it's very obvious, you know, they're they're from Manhattan or something and they, you know, they've always lived in the city and you know, their hobbies are like going to Broadway shows and things like that. It's like, you know, that's obviously not the right person, you know. And so I would say to anybody who's considering us as a backup program, probably don't bother.
David Kenarowski (16:47):
but uh we uh we we definitely uh look for people who have that that rural mindset and you know grew up in a small town and they want to settle in a small town and you know do the outdoor hobbies and things like that.
Dr. Amiri (17:02):
yeah
Dr. Amiri (17:03):
I would agree with what David's been saying. I really spent a lot of time when these personal statements and applications looking at the individual as a whole rather than, oh, what's their board score or or did they honor this rotation or I just want to know, is this a person that can get along with, work with? Is this a person that's interested in the same values that we have as a program? Because I'm I really am I'm matching somebody the exact opposite of a traditional general surgery residency program where I don't want to match train fellowship. I want people that want to be general surgeons. And most of my residents, if not all of them, they're on board with that.
Dr. Amiri (17:42):
And they all know, and I have two of them right now, they said to me they want to go into fellowship. I completely support it. Right? You could change your mind.
Dr. Amiri (17:50):
you're allowed to change your mind. But the the mindset of matching somebody is that somebody who wants to be a surgeon first and foremost.
Dr. Randy Lehman (17:58):
What fellowship are they looking for? Just curious.
Dr. Amiri (18:01):
Uh one wants colorectal. Actually, both want colorectal. Uh one was thinking about critical care for a little bit.
Dr. Randy Lehman (18:07):
Think there's any chance they would do colorectal and then have general surgery still and as part of their practice?
Dr. Amiri (18:12):
I would imagine so. They realize working in a suburban or rural environment, you'd have to do both.
Dr. Randy Lehman (18:17):
Okay, great. I've gotten basically most of my questions answered unless there's something else about the program we can uh do a quick how I do it speaking of colorectal.
Dr. Amiri (18:26):
Sure.
Dr. Randy Lehman (18:27):
Okay Did you have something?
David Kenarowski (18:30):
Oh, I was just gonna say, I I just from my limited experience, I think of all the fellowships, that's probably the one that's the most useful at the rural setting too, so.
Dr. Randy Lehman (18:38):
Yeah, I agree.
Dr. Randy Lehman (18:38):
and you you think of critical care but it's really not because like, I mean, I don't have an ICU at any of the hospitals I'm at. Like, we we literally can't run a person on a vent, we can't run a drip in our hospital like outside of the ER, so like you can't, there's no point in that. It's more of doing high volume low acuity surgery to help keep the hospital doors open and enhance the whole experience of everybody living in the town. You enhance the economic output of the hospital and the community, um you keep jobs local, you make something a community can be proud of. Maybe recruiting uh businesses to your small town might be easier with a functional hospital. Those are the, you know, tax revenue, tax base for the county, all those things.
Dr. Randy Lehman (19:18):
and it turns out being an awesome job for you as a surgeon as well. So tell me about none of the hospitals I op, well, I take that back. One hospital that I do just a very limited, um, backup call coverage thing has a hospital in Wisconsin, or I mean, has a robot in Wisconsin. But the other three critical access hospitals I operate at in Indiana, they are, they don't have any robot, and so I do most of my colectomies hand assist, and it's been, it's worked out really well for me, um, to this point. But there's always a hot topic at all of the conferences about how your rural hospital is going to get a robot. So for the sake of that, um, I know Doctor
Dr. Randy Lehman (19:54):
Mir, you do most of your right colons robotically and David specifically singing your praises saying you got a slick technique. So, uh, why don't we talk about that and um, yeah, and uh, you can just kind of start from the setup. I mean, we all we don't have to do the indications, okay? Let's say the patient has good indications for a right colectomy. How do you set them up? You're going to do it robotically and get us started.
Dr. Amiri (20:18):
Yeah, so um I will say by the way for robotics is a lot of rural hospitals I didn't think were going to get robotics, they have them because it's paper use now, which is kind of interesting. Um and also their funding through FHQHC funding. Um so robot right colons, I've learned from somebody else over the years, I've changed where I put my ports and my mindset is finish the case at the beginning before you you start it. So my anastomosis is the most important thing to me. So I put my twelve, I put four ports in, three eights and a twelve.
Dr. Amiri (20:54):
The twelve port's actually the second highest port in the left upper quadrant. And that will get you, 'cause it articulates, will get you the stapler for the hiligation of the ileocecal. It'll also get you stapled the anastomosis for both the ileum and the transverse colon. So that's one thing. I use a Reteck, a wet Reteck during the case to help with retraction. It's the most underused tool in my arsenal. And I'll also use, sometimes I'll use like a braided suture to help with retraction as a fifth arm instead of having an assist during the case.
Dr. Amiri (21:32):
'Cause having more people in the case kind of gets into the way of uh your workflow. I always do medial to lateral unless I can't for some anatomical reason. And I do a lot more retraction than most people are comfortable doing. I'll lift the the colon straight up into the air, the mesentery, and then dissect the areolar space to make sure I'm in the right plane. But yeah, I do the hardest part first, which is the pedicle ligation and sweeping the duodenum out of the way. And then the rest of the case is the easiest part 'cause the white line of TOL just falls away and your small bowel just goes right up against it.
Dr. Amiri (22:05):
So I do an uh isoperistaltic anastomosis. Um, which, I mean the stapler, the 12 ports exactly in line with the stapler, which is fantastic. And I hand sew my common channel closed in two layers.
Dr. Randy Lehman (22:18):
Okay.
Dr. Randy Lehman (22:18):
So, a few specific questions. If we go back to, um, for the sake of time, we got we got to leave some things out. So we skipped the port placement document. Okay. Now you hold the colon straight up. How do you know exactly where to start on your medial to lateral dissection?
Dr. Amiri (22:34):
So I pinned the cecum towards the right lower quadrant and that causes the ileocecal pedicle to show a fold, um all the way down to the base. And I sweep the small bowel out of the way and it's right there, just follow it to as proximal as I want to go. I make a small window with hot scissors or a vessel sealer, and the areolar plane just opens right up for you. And then I'm able to dissect around the ileocecal pedicle and then the rest, you know, staple and all that stuff.
Dr. Randy Lehman (23:04):
What about when they're pretty heavy?
Dr. Amiri (23:05):
So, when they're very obese, the only difference would be is my ports are probably a little more lateral, I'm doing a little more rotation right side up. Trendomber versus no trendomber just depends on the way their their anatomy lays. And I do use a Raytech, sometimes I use two uh to help with retraction because the small bowel will get in your way when you're trying to do your dissection.
Dr. Randy Lehman (23:25):
Do you rotate everybody a little bit, left side down, right side up?
Dr. Amiri (23:28):
Almost always, yeah.
Dr. Randy Lehman (23:30):
Okay. Um, and so then once you get into the luceral or plane, you dissect the iliac crest. You're doing your high ligation, assume you're using those plastic clips.
Dr. Amiri (23:39):
I I use a stapler, just what I'm used to.
Dr. Randy Lehman (23:42):
And uh, so what state are you in?
Dr. Amiri (23:44):
I use the 45 White Load from the Robot Company.
Dr. Randy Lehman (23:48):
Do you know the stable height on that?
Dr. Amiri (23:50):
Not off the top of my head.
Dr. Randy Lehman (23:51):
No problem. So if you, after you take that, then where do you go next? You go uh cranial and then get the duo down?
Dr. Amiri (23:59):
Yes, I go cranial, sweep the duodenum down towards the transverse colon, and I basically dissect all the way to liver.
Dr. Randy Lehman (24:06):
Okay. And then eventually you're going to get to a point where there's perineum you got to get through on the back side.
Dr. Amiri (24:12):
Correct.
Dr. Randy Lehman (24:13):
just open it up. How do you know how far to go? I guess uh your pathology might determine how far you're going on your transverse colon.
Dr. Amiri (24:21):
Correct
Dr. Randy Lehman (24:21):
But so in any tips or tricks about the middle colic and or right or left branch of the middle colic?
Dr. Amiri (24:29):
So sometimes I'll use ICG, indocyanine green, to help me identify the middle colic. When you've dissected that much out, the vessels will be pretty apparent. So I will actually, I will not use the full ICG amount, which I think is 10 cc's worth. I will give one or two cc's at a time. So I can identify the middle colic if I'm if it's that important to what I'm doing. Um, and then I can mentally map out where I'm going to resect. A lot of surgeons or colleagues of mine will give the full 10 cc's for the anastomosis and then, you know, halfway through the case, like, oh no, I need I need more, right? I've already used a max allotted amount.
Dr. Randy Lehman (25:07):
So, and then for just for the sake of talking indication, so you have a sequel pathology, then you're usually leaving like the whole middle colic intact.
Dr. Amiri (25:16):
Correct
Dr. Randy Lehman (25:17):
transecting maybe a quarter to a third of the way down the transverse
Dr. Amiri (25:21):
Yeah, proximal. Yep.
Dr. Randy Lehman (25:22):
Yep, and then um say you have like a hepatic flexure pathology, then you then uh how do you know where to take the middle colic?
Dr. Amiri (25:31):
Uh, I'll go grossly about five centimeters distal to the pathology.
Dr. Randy Lehman (25:36):
And so meaning that if you if you can leave the the left branch of the middle colic and still get a five centimeter gross, you'll trace the right branch of the middle colic down to its origin and that's your hiligation point.
Dr. Amiri (25:48):
Correct
Dr. Randy Lehman (25:49):
Yeah. Anything else to add to that? Sorry, just like uh sometimes I like to ask uh sometimes I'm asking for myself. Sometimes I'm asking for the listener. But it's the same person because I'm the only person listening to the show anyway, so.
Dr. Amiri (26:02):
You know what? On my long road trips, I would go to Disney like a couple times a year, I'll actually turn on your podcast.
Dr. Randy Lehman (26:08):
Oh man.
Dr. Amiri (26:09):
Davis put me on to it lately.
David Kenarowski (26:12):
that that one-hour drive that I make all the time, I listen to your podcast.
Dr. Randy Lehman (26:17):
Alright. Very good. Well, the student becomes the uh professor or whatever.
Dr. Amiri (26:23):
Yeah.
Dr. Randy Lehman (26:24):
It's all good.
Dr. Randy Lehman (26:24):
Um, so perfect. So then you you've got your hiligation whatever you need to do on the transverse, you've got your uh broken through the peritoneum on the back side, you're kind of bringing that down then, I assume, and and basically bringing basically on both ends connecting to a point where you're going to transect the bowel, right? Anything else to add to that part of it?
Dr. Amiri (26:45):
No I basically meet that perineum from the other side.
Dr. Randy Lehman (26:48):
And the the instrument you're mostly using is the is the vessel sealer?
Dr. Amiri (26:51):
It is.
Dr. Randy Lehman (26:53):
Okay. And then now we get Which one do you transect first? Does it matter?
Dr. Amiri (26:56):
It doesn't matter, but by flow I usually do the ilium first.
Dr. Randy Lehman (27:01):
Okay. And that's a stapler from the company.
Dr. Amiri (27:05):
It is. It's a white load as well.
Dr. Randy Lehman (27:07):
Okay. forty-five
Dr. Amiri (27:09):
Yeah 45 is fun.
Dr. Randy Lehman (27:12):
Okay. And then you go after that's transected, do you do anything with the end to like not lose it or you just just let it sit there and it usually doesn't go anywhere for you?
Dr. Amiri (27:20):
I just let it sit there.
Dr. Randy Lehman (27:21):
A single, sustained musical note plays. And then you go back up to the transverse colon, what do you staple that with?
Dr. Amiri (27:26):
a blue load 45 is so I don't waste more staple loads than I need, but 45 is usually what I use.
Dr. Randy Lehman (27:33):
And usually, does it usually take two or
Dr. Amiri (27:36):
It does.
Dr. Randy Lehman (27:37):
All right, and then you mentioned about holding retraction with a suture. So, where does the suture usually go when you're using a suture?
Dr. Amiri (27:46):
If I'm going to retract with a suture, I'll usually put it on the specimen side so I don't cause injury to the side I'm keeping. Um, and that's very rare. It's not very common I would use one.
Dr. Randy Lehman (27:56):
Like do you throw it through the bowel and then up to the abdominal wall and then tie or or how are you?
Dr. Amiri (28:01):
Uh, I'll usually use a figure of eight either through the mesentery, no not mesentery, the omentum if I can get away with it. If not, yeah, the through the colon.
Dr. Randy Lehman (28:11):
and you stitch it to the abdominal wall.
Dr. Amiri (28:13):
Mhm
Dr. Randy Lehman (28:14):
Yeah. You don't bring it through the abdominal wall, no suture passer thing, clamp or nothing like that. It's just uh stitched up there. Okay. So we've transected, now you've got your specimen. Where do you extract your specimen?
Dr. Amiri (28:25):
Uh, so I change every time I do these cases. Uh, I usually lately been doing a low Fan and Steel incision uh for extraction. I used to do take the 12 port extended to double the size and then extract it there, but I'm finding some more hernias form, so I've chosen the Fan and Steel.
Dr. Randy Lehman (28:44):
When you did the twelve, was it vertical or transverse?
Dr. Amiri (28:47):
Transverse
Dr. Randy Lehman (28:48):
Okay But it's off midline, right?
Dr. Amiri (28:50):
It is.
Dr. Randy Lehman (28:52):
Okay. So then you you got to get the specimen out. Do you do that at the end after you do your anastomosis? Okay, so then you carry on with your isoperistaltic anastomosis. How do you line it up so that it's tension-free for you?
Dr. Amiri (29:05):
Uh, so I will use I use a non-traumatic grasper, it's called a small grasping retractor. I will align both limbs. Usually by this point, the small bowel is just laying right by the colon. Just by
Dr. Amiri (29:19):
gravity. And then I'll make a comma enterotomy into both limbs. And then I'll pass the stapler load, making my anastomosis.
Dr. Randy Lehman (29:27):
So you're roughly um anti-mesenteric.
Dr. Amiri (29:30):
Hmm
Dr. Randy Lehman (29:31):
and you're coming in from left to right and uh you got to make your hole on your transverse colon far enough away that your stapler's not running into your other lined in. So you just kind of roughly eyeball that and then you then your other hole in your small bowel is is like a centimeter off of the staple line.
Dr. Amiri (29:50):
about two centimeters
Dr. Randy Lehman (29:52):
And you bring your staple load in and it's a single load.
Dr. Amiri (29:55):
It is.
Dr. Randy Lehman (29:56):
is that a sixth what do you what do you use
Dr. Amiri (29:59):
Uh, it's a 45.
Dr. Randy Lehman (30:01):
Mhm, and also a bluer
Dr. Amiri (30:03):
I use, well, lately I've been using a white, but blue load's probably what I've been using before. Um, I haven't had a leak from either one.
Dr. Randy Lehman (30:11):
Yeah, if you have a little thicker colon, maybe you lean one way or another, you know. Yeah. Makes sense. Okay, and then you close two layers just uh hand-sewn.
Dr. Amiri (30:19):
Mhm.
Dr. Randy Lehman (30:20):
Um, so you're in what do you use 305 for both of them or what do you use?
Dr. Amiri (30:23):
I use a 3-0 Stryker fix, so I use a single stitch, full thickness, and then I Lambert it with the same suture in a two-layer fashion.
Dr. Randy Lehman (30:31):
Perfect. And then you're going to do your extraction, close up any other, you close mesenteric defect?
Dr. Amiri (30:36):
I don't
Dr. Randy Lehman (30:37):
Okay. For the rights is a huge, you know, huge defect, so it's...
Dr. Amiri (30:41):
Right.
Dr. Randy Lehman (30:42):
set up for tearing and whatnot. Anything else that we missed?
Dr. Amiri (30:45):
Uh, no. No, it's pretty. Uh, no, I don't. I send them up to the floor on a diet, clear liquid diet, no Foley, no NG tube. We actually had um one of the hospitals I work at had shut down the OB floor and those nurses were without any real job title or I guess position there. So we've made that an ERAS floor for hysterectomies and colorectal. So within an hour, they're actually walking the patient, they're getting them up, which is great.
Dr. Randy Lehman (31:11):
You ever discharge any of these patients on the same day yet?
Dr. Amiri (31:14):
I don't have it in me yet. The next day is usually about the time.
Dr. Randy Lehman (31:18):
Yeah. But a lot of them are already on day one, right?
Dr. Amiri (31:21):
23 hours.
Dr. Randy Lehman (31:23):
Love All right. And if you didn't have a robot, then what modification would you make?
Dr. Amiri (31:27):
I would I would do the same operation laparoscopic. Yeah. I would probably very similar actually. Except probably not as facile laparoscopically suturing. put it that way.
Dr. Randy Lehman (31:38):
Yeah, what energy device would you use if you were doing it laparoscopically?
Dr. Amiri (31:42):
I like the ligature.
Dr. Randy Lehman (31:43):
Yeah.
Dr. Amiri (31:44):
I'm I don't I'm nothing against a harmonic, but with resident training residents, I always worry about the the pot tip touching some random piece of bowel when you're not paying attention for like half a second.
Dr. Randy Lehman (31:55):
Yep. I am in agreement. Well, that was great. So, man, you make me want to get a robot, I guess. Kind of go pay-per-play.
Dr. Randy Lehman (32:06):
That's good. Alright boys, well, I appreciate your time. Is there anything else that you would really like to to share with the listener before we take her out?
Dr. Amiri (32:14):
David? Give me anything?
David Kenarowski (32:17):
Sorry.
Dr. Randy Lehman (32:18):
You guys are doing awesome work down there in the Ohio River Valley, so I just really appreciate you um taking the time out of your day to share what you're doing with us. And uh it's just been my pleasure.
Dr. Amiri (32:28):
Thank you so much.
David Kenarowski (32:30):
Thank you so much, Akilah.
Dr. Randy Lehman (32:32):
You bet. And thank you to the listener too for joining us on this episode of the Rural American Surgeon. We'll see you on the next episode of the show.
Timecode:
00:31 Introducing Dr. Amiri and David Kenarowski
01:07 Why Marshall Created a Rural Surgery Residency
02:08 David's Experience in the Rural Surgery Curriculum
03:09 Career Plans and David's Rural Background
03:40 How Rural Surgery Differs by Location
05:27 Tailoring Subspecialty Training to Future Practice
06:37 How Marshall's Rural Residency Is Structured
07:45 What Marshall Looks for in Rural Applicants
08:52 Case Volume and Early Operative Experience
09:41 Rural Sites, Call, and Housing
11:41 Subspecialty Experience at Rural Sites
12:56 Which Skills Matter Most in Rural Surgery
15:58 Who Should Apply to Marshall's Rural Program
17:58 Fellowship Training and Rural General Surgery
18:38 Why Critical Care May Not Fit Every Rural Practice
19:18 Robotics in Rural Hospitals
19:54 Robotic Right Colectomy: Setup and Port Placement
22:18 Robotic Right Colectomy: Medial-to-Lateral Dissection
24:29 Using ICG to Map the Middle Colic
26:24 Completing the Dissection and Bowel Transection
27:37 Retraction Technique
28:25 Specimen Extraction
28:52 Creating the Isoperistaltic Anastomosis
30:45 Postoperative ERAS and Early Discharge
31:23 Laparoscopic Approach Without a Robot
32:06 Closing
