Episode 76

The Rural Surgeon’s Guide to Treating Pilonidal Disease

Dr. Levi Smucker joins host Dr. Randy Lehman on The Rural American Surgeon to discuss his path to rural general surgery, from growing up in Pennsylvania and training at Bassett Healthcare in Cooperstown to building his practice in Goshen, Indiana. He shares how a close knit group of six surgeons has given him strong mentorship, broad operative experience, and the opportunity to develop his own areas of expertise while serving multiple hospitals.

Dr. Smucker also takes a practical look at pilonidal disease, walking through patient presentation, conservative management, the Gips procedure, excision, wound healing, and the Bascom cleft lift. The conversation explores how he approaches recurrent and complex cases, technical considerations for different procedures, and the importance of choosing treatment based on the individual patient. They also discuss cost sharing within local Plain Church communities, an unusual rural surgery case involving an esophageal food bolus, preparing for challenging cases without letting anxiety take over, and why mentorship remains so important for the next generation of rural surgeons.

Key Takeaways

00:38 Meet Rural General Surgeon Dr. Levi Smucker
01:20 From Pennsylvania to Rural Surgery in Indiana
02:18 Why Bassett Healthcare Was the Right Place to Train
02:52 Building a Career in a Supportive Rural Surgery Practice
04:21 Resources and Capabilities Across Three Hospitals
05:09 Finding a Surgical Niche in Rural Practice
05:52 Bringing Vascular Surgery Into General Surgery Practice
06:25 The Broad Spectrum of Rural General Surgery
08:30 Why Rural Surgery Still Matters
09:15 Understanding Pilonidal Disease
11:27 Evaluating Patients After a Pilonidal Abscess
12:09 Treatment Options for Pilonidal Disease
13:05 How the Gips Procedure Works
15:02 The Bascom Cleft Lift Procedure
16:43 Technical Approach to the Gips Procedure
18:13 Choosing the Right Treatment for Complex Cases
20:48 Performing the Bascom Cleft Lift
24:52 Creating an Off Midline Closure
26:03 Coding Considerations for Pilonidal Surgery
27:42 Lessons From Plain Church Communities and Cost Sharing
29:10 A Classic Rural Surgery Case
30:06 Preparing for Difficult Cases Without Burning Out
32:46 Why a Culture of Mentorship Must Be Passed On

Resources Mentioned

Bassett Healthcare
https://www.bassett.org/

Gehrig Surgical Associates
https://www.gerigsurgical.com/

Critical Access Hospitals
https://www.cms.gov/medicare/health-safety-standards/certification-compliance/critical-access-hospitals

Episode Transcript

Dr. Randy Lehman (00:38):

Welcome back listener to the rural american surgeon podcast I'm your host dr randy lehman and today I have with me a fellow uh I hate to say Hoosier because I went to Purdue but you know a fellow resident from the state of Indiana and general surgeon levi smucker so I'm very excited you know most of my people are from montana or whatever and so I'm so glad that you're on the show with me today Levi.

Dr. Levi Smucker (00:59):

Absolutely good to be here and you can say Hoosier I even though I'm not originally from here I'm starting to claim Hoosier so yeah

Dr. Randy Lehman (01:06):

But see in Indiana like Hoosier means IU

Dr. Levi Smucker (01:10):

Oh yeah that is true it is associated with school

Dr. Randy Lehman (01:14):

And I wish you were a

Dr. Randy Lehman (01:15):

Fellow boilermaker you know what are you gonna do But anyway, we have been connected and I know you trained at Cooperstown and we'll touch on that a little bit. But why don't you just bring the listener up to speed on what took you through the various relevant stages of your life to the point where you are now a practicing rural surgeon in upper central Indiana?

Dr. Levi Smucker (01:40):

Yeah. So I grew up in Lancaster, Pennsylvania, but came out to Goshen College. There's a Mennonite connection there. Developed a lot of connections with the community through college, including actually shadowing some of the surgeons here locally. And one of those surgeons just basically kept calling me. every single year in med school and residency and saying, what about general surgery? What about coming back here? And basically the rest is history. He got me after I fell in love with anatomy and fell in love with working with my hands. And I realized that this would be the in a lot of different locations. Bassett in Cooperstown, New York, really intrigued me because they were in a rural location.

Dr. Levi Smucker (02:29):

There was a very broad training that they offered. They were very family friendly. We were just starting our family at the time. And so, yeah, for a lot of reasons, that kind of drew us to there, me and my wife. And I developed a very good training base. And then I came back to Goshen and I've been here for three years with a group of six surgeons.

Dr. Randy Lehman (02:52):

So can you tell me about the landing when you arrived at your first job three years ago and how that's been and how your group is now set up?

Dr. Levi Smucker (03:00):

Yeah. So Gerig Surgical Associates, that's where I'm at. They're a really unique group. It's been a fantastic first job. The mentorship is incredibly strong. So some of these people, like I said, I had. known before when I was a med student and undergrad, had shadowed them. And we kind of, as a group of six surgeons, we really share things together, including our reimbursement. We will scrub each other's cases. We'll call each other for advice. And we are a small private group. have a number of call contracts with different organizations. We cover three hospitals and we really do quite a variety too. And with there being six surgeons. we can each kind of fill our own niche and we make decisions together as well.

Dr. Levi Smucker (03:48):

We have a board meeting once a month and it really kind of has that feel like we're in it together, we're affecting our own destiny, which, so yeah, I really appreciate our group.

Dr. Randy Lehman (04:00):

Yeah, that's great. So do all six surgeons operate at all three hospitals?

Dr. Levi Smucker (04:04):

We can, but some go to the other hospitals more regularly.

Dr. Randy Lehman (04:09):

Yeah. Is there one in particular that you're mostly at or two? Yeah,

Dr. Levi Smucker (04:13):

I am very rooted in Goshen. I view that as my community. That's where I am every day.

Dr. Randy Lehman (04:18):

So what kind of resources do you have at those levels of those three different hospitals? Like, do any of them have an ICU? Do they have subspecialties?

Dr. Levi Smucker (04:26):

Yeah, so Goshen Hospital is around 80 to 100 beds, and it does have an ICU and quite a number of service lines. And then one of their hospitals is a critical access designation, and then the other is kind of somewhere in between. It doesn't have an ICU, but it's not critical access.

Dr. Randy Lehman (04:46):

Okay, so you're practicing the bigger one of the three hospitals. Correct. All right. Is there anything else that I'm missing about that intro to the practice? And I mean, you said that there's some areas where it allows you to specialize sort of, if you will, and kind of carve out your own niche, you said. So what exactly niches have you carved out and what sort of things that are general surgery are you not doing?

Dr. Levi Smucker (05:09):

Yeah. So initially when I came, I was doing bariatric surgery and did quite a few of those cases and had excellent mentorship with one of the more senior surgeons there, was doing robotic sleeves and robotic bypasses. So, but for various reasons, including GLP-1s, not finding a dietician, our center of excellence program, we made the decision collectively to go ahead and discontinue it. We may bring it back at some point, but I do miss bariatrics. I'll be honest, it's harder to practice bariatrics without fellowship training, but when you have a good program.

Dr. Levi Smucker (05:49):

Good mentorship it is possible but currently I'm focusing back on vascular surgery which I did a lot of in residency and we have a service line here for that where we work closely with the interventional radiologists and they're able to do the endovascular stuff and then us general surgeons are able to do the open stuff wow cool

Dr. Randy Lehman (06:08):

So triple a's no open aortic stuff we don't I mean we will if they are ruptured and they need it but we don't do elective openings but carotids and lower extremity bypasses yep AV fistulas yep doing an ax-bifem on Monday. Ax-bifemoral. cool that's awesome Yeah. So see, this is what the listener appreciates. And the listener is myself, just to be clear. Nobody listens to this show. Grandma, she passed away earlier this year, so she's not even listening anymore. So it's just me and you. But the listener is constantly amazed that the spectrum of general surgery or rural surgery, right? So you consider yourself a rural surgeon, do you not? I would, yeah. Right.

Dr. Randy Lehman (06:52):

And one of my mentors in residency told me that you can do C-sections or carotids, but not both.

Dr. Levi Smucker (06:59):

Okay, that's very wise.

Dr. Randy Lehman (07:03):

So you could be a rural surgeon in this place where you have OB-GYN and you have ortho and all the subspecialties, you have an ICU, you have IR, whatnot, GI, like you have in Goshen, and you're doing the breadth of general surgery. But then you can also be a general surgeon in a critical access setting, for example. I mean, that didn't exist when... this particular mentor was going through training, but we just use that as shorthand and everybody knows what we mean now, critical access, where maybe they need a, they don't have any of those specialties and they need a 0.1 OB-GYN and a 0.1 urologist.

Dr. Randy Lehman (07:37):

And you can be those things in many circumstances and you can do the circs and the vasectomies. the ovarian torsion carpal tunnel and things like that and then you know the things that are like level one general surgery basically the hernias the gallbladders bowel obstructions little littler things like that but probably not bariatrics and probably not things that need an ICU afterwards yeah yeah so yeah that's interesting yeah yeah You pretty much agree with that. I mean, you know, when you're out in the middle of nowhere in Montana, it's a lot different than being in Goshen.

Dr. Levi Smucker (08:08):

Yeah, yeah, it's true. And, you know, one thing that Goshen is probably going to become more in the future is kind of like a bit hub and spoke type of thing where some of these smaller regional hospitals may end up preferring more. And so those systems can work pretty well. And I was first town. So got it.

Dr. Randy Lehman (08:29):

And so why, I mean, I get your background, but the question is what draws you to rural surgery and why does it still matter? That's what I ask most listeners, but, and you kind of already touched on it with, I think your rural roots, then your experience there. And, but is there anything more to your story specifically and why you think what you do really matters?

Dr. Levi Smucker (08:48):

Yeah, I mean, I think it just has to it comes down to really knowing the community being rooted in that community and also kind of I like. to drift my practice where the needs are. And so you will often hear from people that they don't want to go very far away. And if there is someone who can offer that same thing more locally, that is very fulfilling, I would say, as a surgeon.

Dr. Randy Lehman (09:13):

Yeah, I would echo that. So I want to dive into the how I do it. So we're going to talk about a disease process today, more so than a specific operation, but I'll be asking specific questions about little pieces of it as we go. And the topic we're covering is pilonidal disease. So walk me through a presentation, like on a med student resident level presentation, on how these people generally come to you and what the initial first steps are. Yeah.

Dr. Levi Smucker (09:40):

So a classic scenario would be a 17-year-old that had pain in their tailbone and got really red. Their mom took a look at it and said, we got to go to the urgent care. And they went there and they got it lanced and put them on Augmentin for seven days. said to put a hot compress on it. And lo and behold, it's cleared up. But they were thoroughly traumatized by that incident. And so they then get a referral to a local general surgeon like myself wanting answers, wanting to know what's going to happen in the future. And that's usually the point at which I see them.

Dr. Randy Lehman (10:19):

Nice. Most of the time, Italian.

Dr. Levi Smucker (10:23):

Or yes yeah something like that yeah dark hair they're not the uh the blondes although I have been surprised I mean it really is people of all all shades all you know all ethnicities all backgrounds yeah so got it but it does tend to be you ever tell patients this used to be called Jeep seat disease no I have not

Dr. Randy Lehman (10:45):

So this is what I was told in residency is pilonidal disease is called Jeep seat disease because in World War II, all the GIs,

Dr. Levi Smucker (10:53):

Young,

Dr. Randy Lehman (10:54):

Greasy guys riding around on the Jeeps all day long. And, you know, basically the pathophysiology, the hair off the back of the neck or off the back falls down here and funnels down and burrows in at the top of the gluteal cleft and creates a little. cyst because all of the hairs follow the same track just like a river and so then they would call pilonidal disease Jeep seat disease yeah yeah my wife has a Jeep but luckily none of us had any problem with this yet so yeah but but what do you tell that patient then so they say the patient has cleared up and then you look at it do you normally see a little pit there Yeah,

Dr. Levi Smucker (11:32):

One or two, sometimes even three pits where a hair may actually be coming out from the pit. And those are more towards the anus side of things. And then usually there's kind of like some kind of a fullness or maybe a scar where things were lanced more superior to that or off to one. side. And kind of those constellation of features are then diagnostic of what is and what has happened. If they still have pus underneath there, I go ahead and lance it again in clinic. But usually it's cleared up. And I actually go ahead and offer five options. And I say it's from least to most aggressive.

Dr. Levi Smucker (12:13):

And the first option really needs to be considered as important, and that's just waiting and doing nothing. Because some patients, you know, won't recur again. They kind of had one flare, one episode. It's probably the minority, but I would say for when the risks of surgery outweigh potential. benefits, I think it's good to probably have two or three flares to really say, okay, now it's a problem. Now we need to do something about it. And so I always present option number one. And then that's accompanied with conservative measures like shaving, hygiene practices, keeping things really washed and scrubbed clean and really dry and avoiding the deep seats and those types of things. So then the second option,

Dr. Randy Lehman (12:59):

Especially the Rubicon. Yeah. They're especially bad. Yeah.

Dr. Levi Smucker (13:02):

Um, second option I offer is the Gips procedure. And that is invented by, I think, an Israeli pediatric surgeon, Gips. And that. involves just pouring out the inside of the cyst, flushing it out really well, basically trying to obliterate the cyst wall. And in my case, I have had some success injecting VISTASEAL fibrin sealant in that. I find it has the one or two I've had that haven't worked is when it's a larger cavity. And because that's just a more space for the VISTASEAL to occupy, more vacuum for the seroma to redevelop or the cyst to redevelop. Option number three, then, is cyst excision with primary closure.

Dr. Levi Smucker (13:47):

And that has been known to have a high recurrence rate as well, 30%, potentially, 20 to 40. It all depends which paper data you're looking at. Basically, you still don't solve it. problem, which is trying to lateralize the sharp gluteal cleft problem. So the fourth option then is more aggressive, and that's this cyst excision with leaving it open to heal by secondary intention. The data would say that that is a lower recurrence rate. because the goal is for it to heal from the bottom up. And so you don't have this premature sort of sealing over and dehiscing and creation of a new cavity.

Dr. Levi Smucker (14:31):

It does require a very special patient who can have someone do a moist to dry dressing and really have to counsel them. upfront that it's a longer wound healing process and we're actually creating a wound that you'll need to heal. And so it's not a good option for like a college student who is not married or anything like that and isn't living with someone who can do this through these dressing changes.

Dr. Levi Smucker (14:58):

And then the the fifth option the most aggressive that I've done several of now is the Bascom cleft lift surgery and that's an actual undermined flap surgery that is kind of in a bit of a lazy s incision with a bit of a notch to try to avoid the anus as much as possible and that That does solve the problem of actually bringing tissue into the gluteal cleft and filling it in. I do leave the drain with that and pull that out a couple of days later. And I do have them on antibiotics afterwards as well. That's kind of a more aggressive option.

Dr. Randy Lehman (15:35):

So do you ever actually do option number three, excision primary closure?

Dr. Levi Smucker (15:42):

That is a good question. Um, I have not yet. Cause I, yeah.

Dr. Randy Lehman (15:47):

There's better options basically. Yeah. Yeah. I mean, I agree. I basically talk about that as a theoretical option, but I don't actually give it to the patient. You know,

Dr. Levi Smucker (15:57):

I say we don't do that because you have a higher rate of recurrence or whatever.

Dr. Randy Lehman (16:02):

Okay. Um, so I'm going to go through the five options. Waiting, Gips procedure. excision theoretically with primary closure but you don't really do it excision with secondary closure now that you've done yes in fact that is in some ways that's my preferred yeah I mean that's kind of the I would say that's the standard yeah that's like the thing that everything needs to be judged by yeah is it as effective as that and then Bascom cleft lift so um are you familiar with So how is that different from the, well, where do you want to start?

Dr. Randy Lehman (16:34):

Maybe we should walk our way up and then we'll get to Karydakis versus Bascom because what I do, I call it Karydakis, but maybe a similar deal, but maybe let's start with the Gips and tell me exactly, technically, how do you position that patient, set them up and what. instruments do you do and how do you do that?

Dr. Levi Smucker (16:50):

So I do general anesthesia prone just because I really like to see right up in my face, you know, what exactly is going on and be very careful and methodical with the butt cheek spread. And so, but yeah, I basically will take like a two or three millimeter punch biopsy and core out the pit. And then I put a lacrimal duct probe and kind of define the whole cavity. And then usually I will make one or two additional counter pits with the punch biopsy. And then I will take a curette and kind of scrape 3D all the sides.

Dr. Levi Smucker (17:28):

I will feed a Ray-Tec or string from a lap pad through and do a little flossing I will irrigate it really extensively and then after that I will kind of localize at that point I don't want to distort things too much beforehand so then I localized including with epi and then I'm confident everything's flushed and cleaned out. I stick something dry in there and make sure the cavity is totally dry. And then I will inject my fibrin sealant and not too much, not to like completely fill the cavity and puff it up, but just enough that it's like layering everywhere in and kind of gluing it shut and sealing it. So, um, yeah,

Dr. Randy Lehman (18:08):

That's actually pretty easy for me to understand that. That sounds great. And So let's move on. So say you have, who's the right person that you would be like, I'm not doing anything for you except for an excision.

Dr. Levi Smucker (18:22):

And packing it with wet to dry okay so someone who like they want the cysts uh totally gone they want something more definitive and they're not afraid of good wound care and they have like a partner who's like very conscientious and slightly medically inclined and they're someone who can you know handle straight expectations laid on them

Dr. Randy Lehman (18:47):

What if they had a z-plasty and three other excisions in the past and they have a BMI of 40?

Dr. Levi Smucker (18:54):

Okay, well, I guess it would depend. So if I really would have concerns that this is going to get close to the sphincter, if I have, and it depends where the dehiscence or the recurrence is. I, of course, try to optimize them as much as possible. If their A1C was above eight, that's a no-go. Standard sort of things like that. But if I really felt that the defect was too large or it was at high risk, I would maybe potentially refer that patient to a plastic or colorectal surgeon.

Dr. Randy Lehman (19:28):

Okay. But what would you expect them to do? I mean, it's not oral boards. It's just a show. Oh, yeah, yeah. That's going to be the natural thing.

Dr. Levi Smucker (19:35):

Sure. I mean, if it was dehiscence, just one little area, and it was more superficial, then I would probably just excise it and heal by secondary intent at that point.

Dr. Randy Lehman (19:44):

I think I might have also, I really appreciate that. We got to talk about what we actually are going to do, but then what the actual options are. And I think I misrepresented the question a little bit. Okay. This is what I mean. They had somebody tried to treat their pilonidal disease surgically like three times. It wasn't you. Okay. Okay. And now they just have been suffering with like extreme refractory pilonidal and they're kind of, and they're obese and stuff. That's kind of the patient. What I'm going at is what I would do. That is a patient to me where I would not offer them anything else besides packing.

Dr. Levi Smucker (20:18):

Okay. Yeah, that makes sense. Because they've failed like the flaps already.

Dr. Randy Lehman (20:22):

Kind of. Yeah. I think that you have a potential to make that patient a lot worse if you keep go it's kind of like a hernia that you keep fixing and fixing you know and you're kind of in a worse situation every time you make a bigger cut yeah so you need to do that one definitive thing I mean that to me that's like the gold sand but I I rarely find myself packing and I'm usually going more to um more for me to carry dacus flat but let's move on then to that like a cleft lift or

Dr. Randy Lehman (20:51):

Which is obviously very cute, you know, way of saying it, but exactly how do you, you set them up the same way for the Bascom cleft lip and then where do you make your incisions and how do you do that procedure? Yeah.

Dr. Levi Smucker (21:02):

So that, I mean, I, my impression is that it's a similar concept. It's like a, you know, whichever, um, side, the majority of the cyst cavity is. based off of you want to cut, make your incision more towards that side so that the good tissue is going to be what you undermine and then rotate over. And so I think the main difference with the Bascom cleft is this idea that as you go more towards the anus, you kind of make make this little circular notch around there to really kind of avoid that.

Dr. Randy Lehman (21:37):

And then the S shape kind of facilitates a little bit of a kind of sheer rotation downwards as well so do you have a an op template for this um there is a pdf that I have referred to yeah do you think you could send me that and I put it up for the listener in the show notes if that's possible okay because you know picture's worth a thousand words but

Dr. Levi Smucker (22:01):

I I'm buying what you're saying then you've got to close it down over a drain and then are you doing like some Vicryls in the deep layer and how do you close the skin yeah so Vicryls in the deep layer and actually the drain so the very deepest layer is kind of almost more like the deepest like almost fascial pre-sacral fascia almost and the drain is above that layer actually and then it's kind of more uh you know two or three other Vicryl layers additionally and then a really good epithelium to epithelium uh Monocryl you do that with the Monocryl okay got it it's very similar to what I do if I'm Worried.

Dr. Randy Lehman (22:41):

I have very low threshold to staple. Oh,

Dr. Levi Smucker (22:43):

Really? Okay.

Dr. Randy Lehman (22:45):

It's so strong, you know, and I feel like if I'm worried about, I'm always worried about dehiscence. Yeah. But if it just depends on the person.

Dr. Levi Smucker (22:54):

Here's a question for you. Have you ever thought about using one of those, the Ethicon PRINEO? That's, you know what those are?

Dr. Randy Lehman (23:02):

I know what they are. I don't have them at my hospital. I haven't asked for them, but basically it's like a surgical glue, but with rebar in it.

Dr. Levi Smucker (23:10):

Yeah. It's like a, yeah, you almost put like this mesh scaffold and then it's like a tape that distributes the tension and you put DERMABOND over that and it like covers it. Anyway, it's, I, I'm a little too scared to, cause I picture all the sort of bacterial burden on that tissue to seal it under, but, um, but I'm intrigued.

Dr. Randy Lehman (23:29):

Yeah. And I'll also use in between, like if I'm depending on the obesity level and whatnot, I'll use some vertical mattress nylons in addition to my staples and everything. I was doing great and I, in several years, I had no dehiscence. And then finally I had a high school kid that just went and I know he just sat straight on it and then it just, everything opened up. But I, you know, ahead of time, the nice part is if you counsel

Dr. Randy Lehman (23:57):

That the gold standard by which everything is measured is excision and secondary closure and so we might as well try to close it but if it doesn't work and you fail you know yeah and then tell them what your percentage failure rate is or whatever yeah then um really we're just back to square one and we can always take it all out and pack it yeah and you'll end up basically healing That's kind of how I phrase it. I don't know, right or wrong.

Dr. Levi Smucker (24:24):

Well, yeah, I mean, I think that is a good way of framing it. And I may actually use that in the future. But I think there are still some patients who the secondary intention doesn't work.

Dr. Randy Lehman (24:34):

As well if like they have these robust uh gluteal muscles and they're really sharp cleft and they start to get that epibole um or they have like it's still the cavity is not filled in so you can still get into issues yeah you don't want I mean yeah what you're doing I think with the cleft lift is what you want to do Karydakis I'll talk about my thing real quick so it's essentially an elliptical incision okay but it's slid over like two to two and a half centimeters maybe off midline to the side where like you said the fullness is from the abscess yeah and then the edge of the ellipse that's like medial is just on the other side of whatever any

Dr. Randy Lehman (25:14):

Diseased tissue is okay and I try to go kind of start there and stay right on the cyst okay so that I take just as little tissue as I need to from the midline and then the other side you're taking some normal tissue away because you're trying to get this cosmetic closure where then you do what you just said release the cleft and undermine and the cut the back cut happens

Dr. Randy Lehman (25:40):

Centimeter and a half down from the skin depending on how much subcutaneous tissue they have and so then it slides over in like two sort of layers okay uh the deeper tissue if they've got lots and lots of deep tissue you don't have to necessarily it depends how deep the cyst goes yeah you know but you just go as deep as you need to get the tissue out and then then that one flap and then it pulls over and it pulls an off midline closure so that you don't have as much dehiscence kind of the idea all right um talk about coding for these oh gee um I you code a plastic closure on the Bascom uh I think I just did an

Dr. Randy Lehman (26:15):

Advancement flap um that is a good question you know I am a little bit spoiled in that I don't think about coding a whole lot um unless the coders ask So you think they're filling it in for you? Yeah.

Dr. Levi Smucker (26:28):

I mean, I definitely mentioned there's an advancement flap with local tissue. I named the layers that are advanced and things like that. Yeah.

Dr. Randy Lehman (26:37):

And you put the square centimeters. Yeah. So then you're probably coding it as an adjacent tissue transfer, which would be like a 14301. And just worth looking up.

Dr. Levi Smucker (26:50):

Yeah.

Dr. Randy Lehman (26:50):

Um how that might affect your productivity and whatnot versus there's three different types of codes for an excision of a pilonidal with one one seven seven zero one and two based on complexity so that's just for uh you to fall asleep at this part of the episode and then we'll practically move on to is there anything else that you wanted to add to that disease process No,

Dr. Levi Smucker (27:15):

Not necessarily. But oh, well, other than that, you know, I actually do like the continuity and the nuance and seeing patients multiple times. What some people may think of as, you know, a pain because like, oh, like, you know, we don't have any solutions that, you know, and they're always complaining and this and that. I actually like walking with patients in those types of situations. So.

Dr. Randy Lehman (27:38):

All right, next section of the show is a financial corner. So do you have one practical money or practice management tip for the listener?

Dr. Levi Smucker (27:44):

Well, it's more of just like a... The thing I've noticed is that the Plain Church communities in the area here, they have various cost-sharing measures and programs. And I think sometimes I scratch my head and think, oh, why don't we all kind of have more sharing and insurance the way they do it? And so anyway, that's been neat to work with those communities.

Dr. Randy Lehman (28:10):

So do you yourself attend one of these churches no it wouldn't be considered truly a plain church it is a Mennonite church though yeah okay because uh plain church would be what amish traditional Mennonite stuff like yeah some more old order Mennonite uh denominations with under the Mennonite umbrella and then and then amish so your church doesn't have a like insurance

Dr. Randy Lehman (28:35):

Within the church no no it doesn't yeah but I bet if your house burned down a lot of people would show up yeah yeah no we have a very very tight night for me here yeah yeah um okay I mean the thing is that I know you have a tight schedule I could just like riff on this for like probably an hour and a half I know I I also would like to I would like to talk about it more Yeah.

Dr. Levi Smucker (28:57):

I mean, we could earmark it actually, just because, I mean, I think there's a lot of possibilities with where healthcare is going and, you know, how payers work and things like that. Yeah.

Dr. Randy Lehman (29:07):

Okay. Episode number two, we'll record some other day. Let's move on to the classic rural surgery stories because I'm sure you have one.

Dr. Levi Smucker (29:15):

Yeah well it's uh it was one of the first times I was on call here in my first year and got uh we were covering a different critical access hospital at that time and it's of course the middle of the night and there's an esophageal food bolus someone swallowed a chicken bone and so first of all normally it's like a chunk of meat so chicken bone hmm I was intrigued But I hadn't particularly been trained interventional GI type of stuff like that. So I was quite nervous. And of course, I always knew that I had my partners backing me up. But I kind of looked up some stuff about the instruments that you could use.

Dr. Levi Smucker (29:49):

Since then, I've become much more comfortable doing these procedures. I knew all the tools and tips and tricks, but, you know, these are something things that I had to kind of convince myself that, you know, you've been trained, you know how to do EGDs. And so, yeah, I drove out in the middle of the night to a hospital I had never been to doing a procedure that I hadn't really done before. And then I got there and, you know, we.

Dr. Levi Smucker (30:15):

Take the patient back as the CRNA is doing the rapid sequence intubation with the GlideScope there's the chicken bone uh in the kind of the piriform sinus and he gets like this kind of grasper thing and pulls it out and I still finish uh an EGD just to make sure everything's okay but As I was driving home, I was like reflecting just how, you know, I didn't end up even technically doing the actual thing myself. And so it just is a testament how you really rely on others and that it's like it's a team thing. And there's if you have a good support system, you can figure your way through these situations.

Dr. Randy Lehman (30:55):

Great. I've had that exact same thing happen to me. I think that if you're practicing rural surgery, you'll find that mine was a fishbone stuck kind of at the vallecula. And same deal. I was trying gagging in the ER, trying to get this thing out. And ultimately, I'm like, we're gonna have to go put this person to sleep. And I'm just gonna have to do it like with a DL, you know, was what I kind of thought.

Dr. Randy Lehman (31:18):

And the GlideScope is the instrument yeah and basically what you need to do with these patients is first off I don't think you have to do the EGD if you don't want to if you know that that's all there is and there's no pain down lower I mean you certainly you know it's not like it's wrong to do that but if I had that patient again rather than torturing her for a while in the er

Dr. Levi Smucker (31:41):

A rapid sequence intubation and just went with the GlideScope and pulled it out and then I would just breathe the patient until you know until we were done yeah yeah that's true yeah I guess I kind of maybe just felt obligated and and yeah he had been eating chicken fast otherwise and making sure there's nothing else going on down there but I think I did the same thing on the case that I did I'm just saying that if you know it's there

Dr. Randy Lehman (32:05):

And then you know it's not like it's going to be an another one but um that is a great uh example of something that I would say most general surgery residency programs are not calling the general surgery resident to do that case yeah but in rural america you are getting called for that all right uh resources for the busy rural surgeon any other tip that you might have that you just couldn't

Dr. Levi Smucker (32:28):

Well, I guess one of the things you had asked me in preparation here was like a, you know, a hard lesson and that kind of ended up turning into something that I do now. That's basically the hard lesson in residency for me was that I would get very anxious about the next day when I was preparing and doing my chart. view and my case prep. And eventually I learned I'm a very early morning riser and I actually get up very early and then do it all that. But the important caveat there is you can't be caught totally off guard on any given day.

Dr. Levi Smucker (33:02):

So then I also work into my week looking at the next week and seeing if there's any like majorly big case. that I need to prepare for on a longer term basis. And so through doing both of those things, chart review the day of and longer term preparation the week before, I'm able to go to sleep more peacefully. Yeah,

Dr. Randy Lehman (33:24):

It's anxiety management, basically preparation. I love it. So exactly what do you do to prepare for the bigger things?

Dr. Levi Smucker (33:31):

Okay, so... I mean, I really do like certain video resources. I mean, I know, you know, probably these robotic videos are great, you know, because they a lot of. of robotic surgery is actually kind of almost visually replicating what you're seeing, what instruments they're using. And so that's been one of the reasons that my robotic learning curve has really taken off.

Dr. Randy Lehman (33:57):

And then... So do you get your robotic resources from DaVinci or do you just watch things on YouTube or some other place?

Dr. Levi Smucker (34:04):

Generally YouTube. Yeah. And then I combine that with some of my old surgical notes from residency just to make sure that the principles are sound. And then, yeah, and then I look into anatomy. If it's regarding like a clinical management question or intraoperative scenarios, then I will spin scenarios out of OpenEvidence.

Dr. Randy Lehman (34:26):

I love it. Well, I think that's about all we have time for. Is there something else that you would like to share before we bring her to a close?

Dr. Levi Smucker (34:34):

Not necessarily. I mean, other than that, I mean, yeah, I think for rural surgeons, there's, there's just a lot of endoscopy and, you know, and people, people said this, you know, before I came to this, this place. And I guess I would just tell. every resident or young attending who's maybe on colonoscopy number, you know, four or 500 that it does get better, but it takes a while. So but oh, yeah, the other thing is just this,

Dr. Levi Smucker (35:04):

So important right in the beginning and what I'm kind of now realizing three years in is that that it we can't take it for granted that it's um it needs to be self that it's self-sustaining like you have to actually work to create that culture for for the next people then as well so beautiful

Dr. Randy Lehman (35:22):

All right. Well, thank you so much for joining us today on this episode of The Rural American Surgeon. It's been my pleasure. Yeah,

Dr. Levi Smucker (35:27):

It's been great. And let's definitely earmark that other conversation because I had a good time.

Dr. Randy Lehman (35:33):

Awesome. And thanks again to the listener for joining us on this episode. We will see you next time on the next episode of the show.

Timecode:

00:38 Introducing Dr. Levi Smucker

01:15 Levi's Path to Rural Surgery

02:52 Landing in His First Rural Surgery Job

03:00 Gerig Surgical Associates and a Six-Surgeon Team

05:09 Building a Niche in Bariatric and Vascular Surgery

06:08 The Breadth of Rural General Surgery

08:29 Why Rural Surgery Still Matters

09:13 How I Do It: Pilonidal Disease

09:40 A Typical Pilonidal Disease Presentation

11:32 Five Treatment Options for Pilonidal Disease

12:13 Option 1: Observation and Conservative Care

13:02 Option 2: The Gips Procedure

13:47 Options 3 and 4: Excision and Secondary Intention

14:58 Option 5: The Bascom Cleft Lift

16:50 How Dr. Smucker Performs the Gips Procedure

18:22 Choosing Excision and Secondary Intention

20:51 Bascom Cleft Lift Technique

24:34 Dr. Lehman's Karydakis Flap Technique

26:15 Coding Pilonidal Procedures

27:38 Financial Corner: Plain Church Cost Sharing

29:07 Classic Rural Surgery Story: A Chicken Bone in the Piriform Sinus

32:05 Why Rural Surgeons Get Called for Cases Others Do Not

32:28 Case Preparation and Managing Preoperative Anxiety

34:34 Advice for Young Rural Surgeons

35:22 Closing