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Maybe put yours off me and if that's all right, hello, everyone. Um Thank you for your patience and sorry about the short delay and welcome to the now 23rd, er, Steer, er, General Club. Um, this is aimed on a colorectal theme specifically. Um looking at er, abdominal wall surgery, abdominal wall reconstruction and some of the related topics are on that theme. Er, we're going to start this evening with a, a talk from MS Tweedle, one of our em and M consultants from Abrook Hospital, um, who has vast experience in a number of fields, er, and having undertaken advanced pelvic lignator fellowships but, er, within Ain Brooks, er, works, er, in our tertiary center, taking complex referrals for intestinal failure and abdominal wall reconstruction often with the two coexisting. Um, and I think it's a great opportunity to, to hear her speak and after that, we'll have a talk from Elise, er, about the, the paper this evening and I'll, I'll give her her due introductions at that point. So, um hopefully without any further delay from me, which going on, I'll hand over to Mr. Um, hopefully you can hear me. Thank you very much for inviting me to speak. I am sorry for, er, sniggering at the, in, in the introduction there, I was not expecting to be introduced as an eminent whatever it is. So, um essentially, uh with the talk, I thought I'd just try and run through some approaches to incisional hernia repair and then just talk a little bit about intestinal failure surgery. I actually trained in Liverpool and um I work with a couple of if surgeons there, which is of abdominal wall reconstruction, I do if surgery at Adam Brooks and I've done a few bits of different approaches to incisional hernias. I've sort of gradually changed my techniques over the years. I'd sort of just kind of run you through a, a sort of approach that I have and hopefully it will make sense. Do you want to start the first slide anise? Is that all right? So this is what I'm just going to talk about. So, just a bit about uh what to think about when you're offering a patient, an incisional hernia repair. Um Some things to think about when uh about the hernia itself and how you're going to tackle it. A few general principles. Um Some sign posts, some evidence if you'd like to read that and a bit of general principles and some algorithms from me are the kind of things that I use to when I'm thinking about intraoperative hernia repair. Um some stuff on technique and just a little bit of intestinal failure stuff at the end, which may just help in terms of your practice. So, um yeah, do you want to start the first slide? So essentially, if I'm seeing a patient in clinic, I generally will say yes to agree to do a hernia repair unless there's some things that put me off. So the things that will put me off is if the patient is an active smoker. So II won't offer them any sort of hernia repair until they've stopped smoking. If they are very overweight. Um I usually ask them to lose weight and to aim for a BMI of 33 it's, it's fairly arbitrary, but that is, that seems to be, there's a sort of consensus around that. Um I know in some places I A BMI of 29 or places like this, but I'm generally, I will say aim for a BMI of 33. If they're slightly over over that, I'll usually um give them a little bit of wiggle room. But if they're really very obese, um it causes all sorts of issues. So, not least with the second, well, the third thing on the list, which is uh the respiratory problems. So usually, uh they're very obese patients, they don't have a lot of intraabdominal space. So if you try to put back inside quite a bit hernia, you can get a respiratory embarrassment afterwards and that can cause a big problem. So even if they just lose a stone sometimes before you, if you have to operate, actually, it will make a big difference in terms of trying to relocate their abdominal contents. Um, generally speaking, I, if the patient is opiate addicted and they've got long term pain issues, then I do worry a little bit. It wouldn't stop me from offering them an operation, but it depends a little bit on what they want. I've certainly had patients come to see me and said, oh, can you just remove all the mesh because, you know, the mesh is giving me chronic pain. And that's a really difficult situation and it almost never will you cure their chronic pain by re operating in that case. And, um, and I usually, you know, end up spending quite a lot of time just trying to talk them through why they might have pain and why an operation is a bad idea. If they're diabetic, I usually like to try and make sure the diabetic control is really as good as possible. If they've got very poorly controlled diabetes, they get really bad wound healing issues. Um, and then slight softening, but if they've got her um, incisions laterally to the midline wound that you're trying to repair, it can interrupt the blood supply. So sometimes if you're doing a midline incision, most of the blood supply is coming up through the rectus. So they get um rectus sheath perforators which will then come up and supply the skin and fat in the midline. If you take those perforators off, which sometimes you kind of have to really, if they've got a big hernia, they can get skin necrosis and it's worse if they've got any deep lateral incisions, like a coccus incision or a subcostal or a nephrectomy incision. Sometimes all the blood supply that comes laterally, they've divided and then you just have to be a little bit cautious and it might be worth then just thinking about kind of approaches trying to preserve the perforators as much as possible. So I'll come on to that after a little bit. Do you want to um change the slide Elise? Um So in terms of the hernia itself, uh usually I start by obviously examining the hernia and the patient. So it's a kind of a good thing to see how easily they can get on and off the couch. That's a fairly baseline if they turn up in immobility scooter and they, they struggle to get on the couch. You on a little bit of a hiding to, I think um the hernia itself often looks a lot bigger than the defect. I like to ct them and measure the defect. You can get all sorts of complicated algorithms. Now for measuring the area on the volume of the hernia sac and the volume of the abdomen to try and work out whether they've got loss of domain or not. I don't use any of that. To be honest, I just look at the size of the hernia, the size of the defect and they just eyeball the patient. Um Most of the time, if the defect measures width wise, 10 centimeters or less, you can get away with a reef stopper. If it's between 10 and 20 you can do, uh you might need augmenting with a component separation. If it's more than a 20 centimeter defect, then you are potentially in a bit bit of trouble. Um I have done uh repaired defects up to 25 centimeters, but they are, they do get very tight afterwards and you need every ounce of space. Um Sometimes those are the patients that really struggle respiratory wise as well because it doesn't matter what their weight is. If they've got a 25 centimeter defect in the in the muscles of the abdominal wall, they are going to struggle when you put their contents back. Um Lots of domain, as I say, it's a bit subjective really, you can get these algorithms to measure it. Um Usually the, the thing that makes the difference in terms of, you know what I will say to the patient, offering them an incisional hernia repair is what their respiratory function is like. If they've got a really lax abdomen and they've got good respiratory function, then loss of domain is not a big issue. If they've got COPD and they've got quite a fatty abdomen as well. They'll really struggle with respiratory failure if you try and repair a hernia with loss of domain. So that's the kind of thought processes that II go through. Um, I think some thoughts about what you need to do with the bowel as well. Um Most of these patients that I've pictured here are just plain hernias. Uh, but some of the patients that you'll see later on in the, if side of things have, um, bowel issues as well and you need to sort of factor in. Ok. Well, what needs to be done intraabdominally? And how might that impact? And, and then I think, you know, the main thing is what's the patient's priority? We've had one or two that have come through that their priority is, um, to get IV cyclizine or to, you know, because they're opiate addicted and then it doesn't matter what you do with the hernia, they're not going to have a good result. So, um, you know, some of which, you know, you just need to have a chat with them and say, ok, well, what is the main, one thing that, you know, I can fix for you if it's just the bulge? Ok. But, you know, the T wall is not going to be back to its normal self, even if you get a good result. If they've got, you know, significant bowel symptoms, they're getting obstructed or they're getting, you know, main symptoms that are interfering with their quality of life then. Yeah, I think most of the time they'll do pretty well with having something done. So, um, yeah, this is just a signpost. Really. The European Hernia Society has got some really good guidance and they've signposted all the evidence. There's a big long document there. So if you go for your exam or something, have a read of that, it'll save hours of your time. Um, I've just put really, probably the main thing from my side of things that I took from it, which is that, um, the European Hernia Society recommends a rectal Rectus mesh approach. So that means that's my sort of priority number one. So if I can get a recto rectus mesh, that is what I will do. Um, they will support a intraperitoneal mesh. But I think you can see there that the caution of if you need to reoperate on them, it's often a nightmare. I've reoperated on several patients with, um, Thai mesh in the abdomen. That's supposed to be non sticky. But the problem with the T mesh is it flops off the abdominal wall and then the sticky side sticks to the bowel and when it sticks, it really sticks. So I don't use it. I don't do any, um, any laparoscopic incisional hernia repair work. I generally do it open because I just don't find that the patients get a very good result. I know some of my colleagues do and they like it. But you know, the patients get a residual bulge there. The time mesh, um, generally, it is usually quite well tolerated, but the staples and the clips used to fascinate to the abdominal wall can often attach bits of bowel and things. So I tend to stick to a retrorectus approach for the patients. I don't think I've put an onlay mesh on since I was in so, and there is usually multiple ways you can avoid putting an onlay on. And I would say if you are using onlay mesh in the emergency setting or electively, I would try and work towards some techniques to steroid from that because the seroma rates are very high, the infection rates are very high. The patients often get like wound that plasters down to the prolene mesh and they get chronic pain issues. So most of the patients who come to see me with pain problems, post hernia repair have had an onlay. Um So I would definitely try and avoid an onlay if you can. So if we go on to sort of this is don't quote this in the exam. By the way, this is like a personal approach that I've kind of a little algorithm that I use in my own mind when I'm operating to try and work out what the best way to fix the hernia is. So generally speaking, I will, if I'm interoperatively, I'll prioritize the posterior layer. So I'm going to open up and do a reef stopper, 99% of the time the reef stopper might become a component separation. Depends on the patient's laxity and how their defect is. Um When I do the reef stopper, I'm in already into the recor recti plane. If I don't have enough tissue to get a posterior closure, then I'll prioritize that over anything else. Because then that gives me much more options when it comes to the mesh. So for instance, um the first port of call will be to stitch both posterior layers together. And the classic kind of ROF stopper approach, but I'll often um preserve the sac. So if I go in and I'll divide the sack down the middle and I'll leave one half of the sack attached to the anterior sheath and I'll leave one half of the sack attached to the posterior sheath. And then that extra bit of sac can just add a little bit of leeway, a little bit of extra tissue to get some coverage. And I was a bit skeptical about that until I saw Salford using it quite regularly, who they are a big if center and they've said they've had some really good results with it. And actually, since I've started doing it, I found that it really works well because it helps just take some of the tension off. It means that often you can do a reef stopper rather than go straight to a component separation. So you're saving the patient some morbidity and you've still got the tar that you can do if the patient gets a recurrence. So I II think it's a really good technique and I've been using it quite a lot. Um If I can't get either of those things, I can't get sack and I can't get sheath, then I will usually use omentum. So I'll make a mental patch and I'll just stitch in a mental patch into the hole to try and make sure I've got coverage. If I can't get omentum, then I'll put in VRL like a four layer. Vicryl, just fold it up and stitch into the gap so that you've got some sort of coverage in the abdomen and then I call it the hygiene layer. Nobody else calls it that, but it works for my mental working out. But um once I've got like a hygiene layer then and a pocket, then you can more or less put what you want in there. So I usually use Proline to be honest. And, and the the evidence base is that actually proline is pretty safe up to type three hernias. So what you can see in the little circle there is the classification of incisional hernias. So like number one is a basic level incisional hernia in a fit patient. Number two is a patient with comorbidities. Number three is a patient with a fistula roso and number four is infected mesh. So there is paucity of evidence in the type three and four. But generally speaking, proline has been shown to be fairly safe. In terms of what evidence there is in the type three, the infection rate has been shown to be a lot higher in the type four. So I would definitely use a biologic in the type four. Sometimes if there's a lot of contamination with the fistula patients in the type three, you know, there's multiple fistulous openings and there's sort of poo everywhere and things, even if I wash out, I'll sometimes choose to use a biologic. The biologic I have normally been using is Permacol, but I'm probably switching gradually to otex, which I've used a couple of times. I think the there is a discussion about um you know, the manufacturers of vertex say it's coated and you can put it inside the abdomen and the same with um you know, you'll find some other bits of mesh as well, like some composite mesh and some time mesh and things. And people say, oh, you can put it in the abdomen and, and I don't doubt those claims, but I saw that with Permacol when it first came out, the people said, oh, it's brilliant. This stuff, you can put it everywhere, just put it in the abdomen and put it in is an interposition. And gradually I think we've realized what the limitations of protocol is. So it does cause neovascularization onto the small bowel. It does um increase the risk of fistulation and it dissolves within a couple of years. So it's not very strong. So, if you put it in as an inlay, people do get recurrent hernias with it, eventually it just turns to sort of mush and they get a recurrent hernia. So, you know, I use permacol quite a lot, but you've got to be aware of the limitations. I don't put permacol in the abdomen and I don't put proline in the abdomen to date. I haven't put otex in the abdomen either. So I've used otex a couple of times and it's a bit stronger than Permacol and it's nicer material to stitch. But I would still choose to put it in a rec to rectus position. So, on top of my hygiene layer and not underneath it. So that's generally my approach. Um the anterior sheath, I think you get a bit of a freebie because most of the time you've got some anterior sheath that will close over. If it doesn't completely close, you can just stitch it down to the mesh. II call it a Teletubbies window. But essentially you can just plaster it down to the mesh and just stitch it all the way around. Quite difficult with Permacol because current Permacol is so difficult to stitch. So which is why I've probably going to move to Ovitt to do that because it's a bit easier to stitch it. Um If you're stitching it to, to proline, which you can, the only thing is I normally cover the proline so that you don't get proline on underneath the skin because then you'll have that kind of onlay effect and they get a really bad seroma. So I will cover the proline with something. The easiest thing to cover the proline with is a four layer piece of vicryl, you just get a bit of a folded vitral mesh and stitch it in the defect and cover up that proline and it will work really well. It just turns into just a layer of fibrous tissue, which is all you want really because once the prolene embeds in, you're going to get a good quality repair. So that tends to be my approach. And I know other people have different ways of looking at it and some people will quite happily use it intraperitoneal and the hernia society will support that. But for me, I just think this is the easiest way because then if I just prioritize getting the posterial layer attacks, I get free rein I can use pretty much whatever I like to reinforce the repair then. And um you know, I can, I more or less build up a sort of way of doing it every time. So that's my approach for what it's worth just to kind of give a little bit of a, a sort of overview, I think. Yes, next slide, I've just, most of you all know this already, how to do a reef stopper. I've just put some pictures in here, but essentially you're looking at incising the edge of the rectus muscle and peeling off the posterior rectus, make sure that you sweep the vessels and the fat pad up with the rectus muscle. When you're doing it, you got to be really gentle with the rectus muscle. If you put a big clip on it and hoik it, it'll bleed and it will cause problems for you postoperatively. So try and put a nice soft swab on there and just retract it with fingers is probably best that plane will just separate with blunt dissection. It's really nice. Um What was I gonna say something? Yeah, on this clip, they've got the um, rectus muscle being lifted up and the incision being made on the underneath. If you do that, if you've left any sack attached, it will attach to the anterior sheath and you can use it to fold on top of any mesh that you put in, um, to, you know, cover it if you do it the other way around. So it's not shown on this picture. But if you pull down the mesh, the abdominal wall and you incise on top, you go in on from the top downwards onto the rectus and still get into that rectal rectus plane and lift the posterior, the rectus off. So you're going posterior to the rectus, then you'll leave the sac on the posterior sheath and then you can almost use that to just augment both of your flaps then. So that's what I usually do. You've got to be careful not to strip the anterior rectus sheath off the muscle because that's where all the vessels are coming up like this. And you take all the perforators off and then you'll get some skin necrosis, plus it will bleed and it will be, look like a real mess. So, always go in underneath the rectus and then lift it all up and be delicate. Um If you want to go to the next slide, Anneli, so actually a tar is just a glorified reef stopper. So there's nothing too complicated about it. I just, these operations are pretty easy to be, to be honest, I think, um when you get to the edge of the rectus muscle, you'll know you're at the, at the edge because you'll see these little curly vessels come up from the posterior lamellus. So at the edge, the, the you'll see on the diagram that the, the top and the bottom sheet they supposed to fuse, but they don't in the exact same place, they sort of separate slightly still and the nerves come in from the bottom and they look like little fine curly lines and you can sweep them, but there will be a point at which they are inserting. What you want to do is to go inside of those little nerve endings by about two millimeters and make an incision going downwards because what you're aiming to do is to get into, you're aiming to expose the transverse abdominis muscle. Now, it's easiest if you start in the upper abdomen. So start in the upper abdomen because you can see the fibers. So they come in under the muscle like this, you can see them coming in and you can come down onto them, take the top layer off, hook them, always hook them with a lady and then gently separate the fibers, divide them. The layer underneath that is super thin. It's just peritoneum. Now, if you're lucky, and you've got a patient who's got a very small abdominal cavity, you sometimes can be in retroperitoneum already by then. So you're kind of in kidney fat and you don't get those little lace curtain like holes. If you're unlucky and the patient has had a bowel resection or they've just got a massive abdominal cavity. When you do that, you'll be still on peritoneum and you can really, really easily make a hole. So you've got to be just really, really delicate and you'll lift those fibers divide them as you come down below the arcuate line, it will turn from muscle into um fascia and you just divide that and you'll access this kind of pre peritoneal plane going all the way around the back of the kidney and it's a huge plane and you get a lot of mobility um doing that, it works really, really nicely. But um the bits of holes that you can sometimes create in that kind of really thin layer. Once you've done the immobilizing, I usually stitch them up. So I just, with whatever, a bit of acral bit of gds, but just make sure that the holes are closed so that you're not getting bits of bowel poking through and interfering with your repair. So that's, that's all it is. And then with the aim to close that posterior area in the midline these days with the tar. So when I first started doing these, I would always do a bilateral tar because that was the description and that was, oh, you know, you need that space, do a bilateral tar. Now, my most common operation is a unilateral tar and particularly useful for patients who've got stoma on one side and it's a bit fibrotic and you want to get beyond it and you can't quite get beyond that fibrotic band. You can't get the release. If you do a tar and you're on that side, you get beyond the fibrosis, you can get a lot more mobility and then you just close the stoma hole and you've got plenty of space. So I often do a unilateral tar, a reef stopper on one side tar on the other side, get the midline closed and then, you know, just measure your pocket and put something in. But it's quite a versatile, versatile technique. The only thing I would say is that, um, we have a few patients who've had a cystectomy and the cystectomies that when they do the cancer resections, they take out the, basically, they take some of the transversalis out when they take the urea out. So below the arcuate line. So sometimes the peritoneum has got a big hole in it when you finally kind of get all your tissue freed up. And you find that actually there's a bit of a space. Um The last chap I did had just an enormous hernia post cystectomy and he's had multiple previous repairs and he just had no posterior sheath at all from the symphysis pubis up to about the umbilicus. And eventually, what I managed to do was use sac, I just folded the sac in and I just put the sac in that space and um, and attached that and it worked really, really well. You don't, it doesn't need to be anything special that coverage. It just needs to be something, whatever you've got and even a bit of devitalized sac, you can, um as long as it's attached somewhere, you can stitch that in for a bit of coverage. But that's just to be aware of, if you've got a patient who's got a cystectomy, you may have to plan to save some sac to put in that space. Um, should go to the next side. I feel like I am talking at you. I hope this is helpful. Um I thought probably what we'd just do is I'd touch on a little bit of intestinal failure surgery. Uh, just because a lot, often the abdominal wall recons and the if surgery they do like interlace sometimes. So in terms of intestinal failure surgery, I mean, this kind of basic level stuff you might need for your exam of just types of if, but essentially, you know, if your bowel is not meeting your requirements in terms of absorption of fluid electrolytes and nutrition, then you've got intestinal failure and you can have a short lived intestinal failure, which is type one, if it goes over 28 days, it becomes type two. If it's irreversible, it's type three. So most of the patients, we operate R in type two. So it's the kind of patients that you've got where, you know, they've been defunction and they've had a loop of, of sort of mid pulled out because they've had a hernia repair and there's a bit of black bowel and they were too doxic to join it and they've got a loop stoma and it's high output and they're on home fluids or they're on home PN or they've had an anastomotic leak and someone just pulled something out of the abdomen or they fistulated or something like this. So, those are the true type two failures. Um Should we just see what's on the next slide? I've completely forgotten what's on the next slide. Oh, yeah. Some etiology, I think to be honest, most of you will be pretty much aware of the causes. What I would say MESH is on there as well, isn't it? But yeah, that is one of the causes of intestinal failure is, is a mesh disaster, which is one of the reasons I don't put it in the abdomen. Radiotherapy is surprisingly sneaky. And we've had a couple of people who've had really horrible radiotherapy related strictures in the small bowel. And they often are accompanied by a stricture in the sigmoid colon as well. They've had really intense pelvic radiotherapy. So you've just got to be careful if you are dealing with the radiotherapy stricture that there might be more than one, obviously, surgical issues, surgical complications are a big part of if and you know, probably the most important thing about intestinal failure, surgery is learning how to prevent it. So, if we go on to the next slide, I think so, I mean, essentially most of the, if patients that we see coming here have had something done at the wrong time that that has potentially just worsened the situation for them. And it's not necessarily the wrong thing that they've had done, but the timing has been poor and then they've developed a complication. So if you go on to the next slide and we'll just, I mean, essentially the main thing is the 10 to 100 day rule is don't operate if someone has had a laparotomy don't operate between 10 and 100 days. So the reason for that is that they get very sticky adhesions and then you try and go in the bowel wall integrity is softer than the adhesions that have newly formed and the bowels like blotting paper. So as you go in, you just peel off chunks of the bowel wall and the whole thing just shreds and falls to bits. So the only reason to go in between 10 and 100 days is if you've got bleeding peritonitis or ischemic bowel, that's the only reason if you've got a collection or you've got bowel obstruction, don't go in the abdomen, you can manage it conservatively and you can pick it up and at day 100 when they've recovered. And, um, you know, it's painful. We sometimes have patients sat here that have had a complication and a dial bile obstruction. They've missed the window to go back to theater. It's not resolved as we thought it would resolve and they sometimes sat here for three months on PN. But, um, it's, the subsequent surgery is much, much safer because then you can release the adhesions and they don't get a fistula, they don't get multiple holes in the bowel. So that is the kind of, you know, it's not an easy decision making process to not go in. Sometimes the easiest thing is to go in, particularly when you've got a lot of pressure from the patient, you've got a lot of pressure from the patient's relatives. But this is why you need good colleagues. You need a combined approach and you need to be, you know, you need to be in a situation where you're not having people sneaking people back to theater in the night or deciding unilaterally that they are going to do. Xy and Z if you've got a complication, lay it out there, get your colleagues support and, and a make a dual approach plan, it will save your sanity as a consultant and it will definitely help to reduce complication rates. So, um, yeah, I mean, if it goes wrong, don't panic uh to get a fistula, the main thing is really just the basic stuff, resuscitate them, manage their sepsis, get them onto some intravenous nutrition, shut the bowel down. Don't go back in and try and do anything else. Um, you know, and the main thing is that to say to the patient, you know, it needs time and, um, you know, immediately and the main thing from the surgical side is to counsel them about the time required at this stage when it goes wrong for things to settle down and that there are options for them to stay at home with intravenous feeding. They can go home, but they need to get the strength back before we tackle it again. So, um, yeah, what's on the next slide? Oh, yeah, just a bit about managing the sepsis that is, um, sort of want to teach you to suck eggs. So, let's move on to that one. so we talked about this already. Don't go back in unless you absolutely, absolutely have to peritonitis ischemia or bleeding. Um, if you can, uh, close the abdomen because this lady with a picture here that's got an open abdomen. Um, those bowel loops are gonna be at risk of fistulation and that abdomen is gonna be an absolute nightmare to close. So we get a lot of patients who've had laparostomy wounds for weeks and they keep having the thea put in and then changed and then somebody swells it a bit out with Saline in theater and puts the athera back. Try not to do that. Usually if they go back for A R look is a really good plan. We re look at a lot of patients, but once they've been relooked once, maximum twice, get that ab out and close her abdomen. Worst case scenario, something happens and you know, they get a complication and they need more surgery. You're not going to do it anyway. At that time, once they get to day 10 and they start to all cocoon off you, you're not going to go back in and start picking up about those bowel lis. So there's no point in putting the azera back in multiple times like 5 to 6 times, just take it out, close the abdomen. You will have a much, much friendlier abdomen to try and deal with once things have healed than if you leave it open. And the patient's morbidity when you leave it open is really high. So that just a plea. Otherwise, I think what's the next? Yeah, I mean, um, the usual snap approach this comes from Salford. So the sepsis nutrition um define the anatomy and only then when the patient is, well, you plan a procedure. Um, what's the next one? Uh So yeah, I mean, just a bit about this, the obviously the more balance you can preserve the better. I do take out a lot of bowel when I do these cases. So, um, I try and only make one anastomosis because usually these patients have already leaked once or they've had complications. So I try and simplify as much as possible. So, if they've got anything over 2 m, I'm happy with that, you know. So if they've got 3 m of bowel and they've got a big section of fistulas in the middle, I just take it out. I don't try and repair multiple bits and give them like loads of anastomoses. So the simpler, the better for these patients, the only time I would start to think about it is if I'm likely to leave them with less than 2 m or they're down to like between 152 m and then you start to think, ok, maybe I'll do two joints to try and preserve the length of bowel. But, um, yeah, I'm sort of fairly ruthless. Uh, a lot of the time I don't try and kn bow back together. That's clearly not gonna, not gonna go. Um, I would say I've put quite a few people back together who don't have any more small bowel but have colon out of circuit and it's still beneficial to put the colon back into circuit because, um it helps massively with their fluid balance. So a lot of them get renal failure because of high output. You know, if they've got an Genos toy at 60 centimeters or something, they get a lot of fluid losses and they gradually get renal impairment over time. It's really difficult to keep up with their fluid demands and it's very depressing for the patient at home. They're on three or 4 L a day. So it's hard for them to go out anywhere. So, actually, if you join it back to colon, you know, they're still not gonna be able to survive nutritionally without support, but their fluid losses are much, much better and that is often worth having for the patient. Um Just uh Aglu Tide is a new nice approved drug that we've not started using yet, but it will come online this year. It is basically, um it's like a growth hormone for the lining of your small bowel. It can't be used for people with cancer because it is um you know, it's oncogenic, basically uh over a long period, but it does improve the surface area of a small bowel and improves absorption. It's supposed to be the equivalent of adding an extra 50% length of small bowel onto what you've got. So for those patients who are running at like 1 m, you know, aglu tide could really make a big difference for them to get them off PN. So that's something that is coming online in the next kind of, you know, six months or so. Um Other than that, yeah, I mean, try um and adopt a sort of preventative approach for going back in and doing any damage after you. If you've had a complication, get your colleagues involved and stick to a team, a team plan. If you do need to do a reconstruction um plan with your nutritionist and make sure that your nutrition is good, you've got the anatomy defined and then decide what you need to do if I need to do an Abdo wall reconstruction. At the same time as I do, I have surgery. The main thing I've learned over the last few years of doing that is not to make the abdomen too tight. I think I've had three leaks in the time in the last sort of three years. So the leak rates for the if patients are about 20%. So they are a high risk group. Um But the two, the first two leaks I'm pretty sure because I made the abdomen too tight. So I wanted to get that closure. I wanted it to be, like, looked like it did in the textbooks and to be all the, you know, anatomically, correct. But actually using a bit of sac, using a bit of their own tissue to try and make it a bit laxer and accepting that good enough is fine for the abdominal wall part of it. It just needs to be sturdy enough for them to go about their daily life. It doesn't need to be perfect. That is actually, um is probably a better approach than making these, all these um abdomens too tight. And then they get a little bit of relative ischemia in the abdomen, they get high pressures and the joint doesn't heal as well. So now I'm pretty keen to try and sort of make it, you know, it, it can't be lax, but it's um, you know, I try and make sure that it's definitely not tight and if it is looking tight, I'll just leave a little bit of a gap and interposition. I accept that there's going to be a bit of a Teletubbies window and I'll, I'll just utilize that. I would rather than make them too tight and risk them leaking. Um I would just say that in some units that have got a robotic abdominal wall service, they do it in two stages, so they'll do the bowel part and then they just close the hernia sac, assuming the patient's got a bit of sac to close, they'll just cobble it back together. They'll sometimes just put a little bit of VR in there to make sure the whole abdomen doesn't fall apart and then they will bring them back in a few months and do a robotic T. So that is an approach that is probably going to evolve as robotic tar becomes more prevalent. We're not doing any here at the moment, but as it starts to become a, you know, well used, um, a well used surgery and a well used approach, we'll probably find that that becomes more and more prevalent with these, if cases we'll do them in two stages. So, yeah, that's it. I don't think it's got anything more exciting to say. I hope that's not gone on too long. It's on a bit. Thank you very much doctor. That was excellent. Um, I have to say if, if I hadn't been in Aden Brooks, it's the kind of talk that I would have loved before the exam. Uh, I think there's some really useful bits in there. So I'm, I'm sure all of our participants would have, would have found it really useful. Ok. Well, I have you got any, if you, if anyone's got any questions and then, you know, that was what I was gonna put out actually. Um, no one's put any in the chat. So, does anyone want to either put it in the chat or unmute themselves while we wait for that. I actually had a, a quick question and you, you sort of touched on it for the robot but I wondered, um, putting the robot to one side, do you ever, er, consider a staged procedure for these, if patients with complex hers, say, for example, if you're giving them multiple joints and, and you're a bit more twitched about them and you, you've sort of been forced into a, a more difficult if case, do you then plan to do the, um, the, the abdominal wall bit at a later date or do you try and do it all in one go? Yeah, I haven't done it to date. To be honest. I think I have simplified the, if operation, sometimes I'm the I FSA operation I get worried about. So, a couple of patients have been obstructed and I know they're obstructed. And one of the reasons that they're very ill is because essentially they're like leaks and the joint is sort of stenosed or whatever. And then the proximal bowel is very distended. And I have to stage them then where I've just taken it out and give them the stoma to let the, um, to let all the bowel sort of distension settle. And for the patient it is a nuisance in the sense that they get a high output stoma, but they often feel so much better when you've relieved their bowel obstruction and then I'll bring them back and reconstruct them, offer them a reconstruction, an anastomosis sometimes at a later date. So I have done that once or twice. And I have one lady circling at the moment that I said to her. Look, I'll join you but you need to stop smoking and she hasn't yet. So that will be the next task. But she's, I've told her that I'm not going to reoperate on her unless she stopped. But she's, um, yeah, that's, I'm more likely to do that than I am to get the, with the abdominal wall. I'm tending to do slightly less. So I'm not doing as much. So I'll often leave at least one of the tar planes free in case there's more needs to be done. There's a recurrence or whatever. I'm using more sac. And, you know, when I first started doing these, I thought, well, I can't use a sacs a bit too tatty. It's not going to be good enough, you know, it's not going to be strong enough, whatever, but actually it worked really well. And the, the mesh that you put in in the middle that particularly if you can use Prolene because it's much stronger. So if you can use safely, use Proline, you know, you get that really sturdy repair and then you've still got a TPL to use if there's a problem. So I'm kind of doing that as a more or less a rough approach at this stage, but I haven't got to the stage where I'm just closing the sack and coming back at a later date, unless they're going to let me have a go on the robot. So that will be, that will be the next thing we'll see. I'll, uh, I'll save the other questions I had for you. There, there's a couple in the chat and I think I'll probably just, um, ask the first one and then if there's a bit of time, the second, but we'll, we'll see how you get your teeth into the first. So we have a Sharon J who's asked, um, in the acute setting with Rooker, what would you do to get the fascia closed if it is significantly in, would you do an acute tar or just vital mesh and plan to come back later electively to repair the hernia? Oh, hi, Sharon. Yeah, definitely. I mean, basically we've had a couple of these where, you know, they've had a trauma or something like that and they've had a ar they've not been well enough and by the time you relook them, they're like day 45 and already the sheaths retracting a bit. We don't do much, uh, mesh mediated traction, but we've had a couple of patients that we've done it with good result and particularly the big sturdy guys who got a lot of muscle and the muscle is starting to retract already or put some proline mesh in, stitch it all the way around and then cut it down the middle and then bring it together and rest, stitch it every time you rook them and within a couple of rooks you can usually take it out. So the A needs to go in underneath the mesh. So you got the athera on the inside and then you stitch the prolene mesh in. And then when you do the mesh media traction, you cut it down the middle, you take the athera out, put the athera back in and then like overlap the, your cut and resit it so that you're making the defect smaller each time. So we've definitely done that. I would definitely not do an acute ti think if they are, if they're really, really struggling and you absolutely can't get them back together. Just vitral, put some vicryl fold a bit vital in there. It needs to be at least four layers. Otherwise it just disintegrates. But if you put some four layer, Vicryl in and just temporize the abdominal wall, often, if you can even just get the skin closed over some VRL, they'll be fine, they will manage with that. And then you can live to fight another day. But often these patients are just, you know, you just got to get them out of the acute problem and then you can start to deal with some stuff. But yeah, I wouldn't do anything acutely in terms of hernia repair at that time. OK, thank you. Um I think um if you can briefly touch on the last question and then we'll stop at that point. Um When would you consider bowel transplant in the setting of intestinal failure? Is there a hierarchy of treatments to follow? Um Yeah, well, II mean, I would qualify it, but I say I'm definitely not a transplant surgeon. Um But y here generally, we do get a few people trickle into the eye of service via transplant. And I think, you know, the transplant team here are pretty good and they will consider all comers. I think the what will put off the transplant team is comorbidities and age. And generally speaking, you know, the older patient is, they're a bit comorbid, etcetera, etcetera, particularly if they've had some kind of cancer in the past and that kind of thing, they don't want, they won't want to immunosuppress them. So they often will say, can you just sort of maximize whatever bowel they've got? So sometimes they'll come and they'll have, you know, I 45 centimeters to a fistula or an angiostomy, but they've still got some colon, colon inside and will often anastomose the colon back onto the small bowel and try and get them into a more functional. And then you plus a bit of lu you might actually get them to a, to a point where, you know, they've got a reasonable quality of life. They're having PN maybe three or four times a week. But they are thriving on that and they don't, they need a transplant, but that's the kind of thing. Um, anything portal hypertension tends to be a bit of an issue. It wouldn't totally put off Andy, I'm pretty sure. But it, it, it does create surgical problems. So, um, yeah, there's a few things but I think if it's, if there's a benefit, you know, give it the benefit of the doubt, always ask them if they think they need optimizing first, they'll often pass them into if for a bit of tinkering up and then see how they go. Thank you very much for that. Um, so I think, um, as we've got no more questions there and we're a little over time, we'll end that um part of the general cloud. And thank you again for, sorry if I've gone on. I find it quite difficult to gauge what time it is when you're on the, speaking on the phone. I hope it's not been too bad um with, on the phone and the volume has been ok. You can always email me if you've got questions or you want a copy of the talk. Not a problem. Thank you very much. I'll see you later. Um, at this point, uh I'm going to hand over briefly to, er, Megan who's, er, here from advanced medical to briefly talk to us about, er, um, obviously we're a little over time So um if if I can politely ask for any brevity, that that would be brilliant and then we'll we'll close out with um an of these talk. Yeah, no problem. I'll just share my screen now. Uh So can you see my screen? Ok. Yeah, yeah, that's perfect. Thank you. Perfect. Yeah, sorry, I'm aware of time. So um yeah, my name is Megan. I'm from advanced medical solutions. Um and we're I'm gonna be talking about our liqui band fixate device. So this is an atraumatic hernia fixation device using glue to fix the mesh, opposed to sutures or staplers, anything which is gonna er penetrate. So with the glue you're able to fix the mesh um in areas which um you won't be able to do so um with the alternatives. Um an and my colleague, I'm just stepping in um as she looks after the territory um um where the and the territory um that you are all from. So at the end, there are some of her contact details. If you did want to get any more information or if you wanted to arrange um to meet up with her, she'll be more than happy to do so. So I'll just go through these um slides. So a little bit about us. Um So we're a UK um company, we're based in Winsford, which is in Cheshire. Um We have been around for over 30 years. We've got a whole host of different um a number of different products and, um, devices as well from, um, our liquid band glue, which you might be familiar with, um, within the operating departments in A&E minor injuries, um, as well as our sutures and staples and hemostats, um, as well. Um, so just to go over a little bit more about, um, the, um, devices, so you can see on the screen you've got the long cannula, um, above, um, which is our laparoscopic device and then below, you've got our open device. Um, so yeah, those bullet points is what I've gone over. Um, it's an alternative to tackles and sutures and it allows you to fix um, wherever you want. So giving you a lot more freedom and flexibility, um with the likes of the Triangle of Doom and Pain. Um, and you can see here with this visual and again, if you need, um, if you want any more literature around this or any videos as well, um, then please do get in touch with myself or Anna. Um, and yeah, we'll be more than happy to go through that. But yeah, the setting time for our glue is 10 seconds. You'll be able to see it pom which goes through the mesh. Um, so you'll be able to see that and you'll be able to see that it has been set, um, when you're putting against it as well, um, with our open device, um, you're able to come out and actually, um, er, close the wound as well with our, um, with the glue. Um, and with laparoscopically you're able to close the peritoneal as well with um, the glue. Um, just a little bit of an overview of um the strength of our um fixate of the glue compared to the likes of secure strap and a Zorba attack. Um So that's really nice to see in a really good visual. And again, we've got lots of clinical studies around the strength of that as well, um which we'll be happy to share with you, um, with the Liqui band fixate laparoscopic, you'll get around er, 30 liquid anchors which are all have a pre precise um volume, which is the 12.5 mg. Um You've got on both of the open and the laparoscopic, you've got three hours that it will remain, er, primed. So, um with the scrub team, if they wanted to prime it at the start of the case, then absolutely, they can, they can leave it. Um, or um if you're doing bilateral as well, you can also um use that and um, for that time it's plenty for the cases you're doing um, 18 month shelf life, um, doesn't need to be stored in the fridge. It comes as you can see on the screen. Um, there are a couple of priming steps which again, um, will give support on as well, um, with the open, very similar um to the laparoscopic. Um, the biggest thing is the priming is a little bit different. But again, we can go into more detail if you want some more information mesh possibility. So we do. Um it is, there's, yeah, we're compatible with a lot of mesh. And again, if there was a particular mesh that you were interested in, we can pick that off offline um with Anna. Um but finally, just to go through, it's a learning curve using our Liqui bar fixate, um especially when you're closing the priority. Um But it's an atraumatic um device giving uh patients less pain after the operation. Um and also giving you a lot more freedom of when you fix the mesh as well. Um We're happy to provide support obviously through evaluations. Um It's a learning curve for yourselves, but also for the scrub team as well. Um There's Anna's details on the screen as well, but if you did want to get in touch with us as well, you need to get in touch with us through our website. Um But like I said, Anna looks after that territory and is more than happy um to reach out. Um and um go into more detail because I understand it's probably a bit of a whistle stop tour. Um But yeah, if you need anything then do get in touch. Um and we'll be happy to go through that. Um But yeah, that's everything from me. So hopefully I don't go on for too long. For you. Thank you. Thank you very much. I'm sorry that you are under a bit of time pressure. It's an interesting bit of bit of kick. I know I've always been worried sometimes tacking things in about what you're Pran. So, yeah, thank you very much. Thank you very much for having me. Thanks for keeping to the time. That's very kind of you. Thank you. And um, last, but no means least we have um Mr Ksor who's one of our ST well, now ST eight trainees, um who is gonna talk a little bit uh about the, the literature related to small bites, but also some other components. Um I think she's exceptionally well placed to give some great tips on uh generally assessing papers with a strong research background and lead on the sub of Dukes for research. But also I think most importantly, having recently completed Fr CS um got tips hot off the press. So I'll hand over to a Thanks Brett. That's very kind. I'm just gonna share my screen again, um very aware of time and not wanting to keep people. And the Rory just had a quick look at the talk and tried to cut it down a bit because II um because there's quite a lot of things that, you know, you could say and I want to take you through a paper as well. So what, what I wanted to do was just, um you need, you need a little bit of background for the exam on small bit closure. Um So I'm just gonna show you a bit about what the um dominant literature says at the moment quite briefly. Um And then the plan was to discuss an article from B Js which is the plan. Um It's a very similar article to the kind that you get in the exam. It's not too long. Actually, I think the some of the guys on the column road next to me got this paper in the setting. Um And so I just wanna give you a really clear idea of the sort of thing that you need to do and a few tips along the way. So, um the idea of small bite closure is that uh the tension is uh the force is distributed more evenly across the wound. Um And it's also thought that it might therefore avoid the button holes which you get, um which is thought possibly to do with partly the tension and partly from the um the bigger needle size. And so it's sort of um gained popularity um for some time. Now, now this, there, there were, this is the paper which often gets quoted the stitch trial. There were, there were small um some randomized controls prior to that, they were pri mostly single center. Um So this was sort of considered to be the first sort of well done trial, um double blinded Multicenter RCT. And so this was back in, er 2015 and published in the Lancet. Um and it was prospective and obviously, and they showed it was based in the Netherlands. Um And they found that uh there was a, a significant reduction in uh incisional hernias in elective cases, er, where they were managed by small, by closure rather than mass closure. Um And II think it sort of just important to, to note though that when you look at the P value of that, you know, this is P value is naught point naught two. So that means, um, it's no, it's less than, you know, naught point naught five, but it's not sort of very, very, very strong. Um, and this was later or one year and then it was a 560 patient. So this is really what kicked it all off. Um, there was a Cochrane review, um, a couple of years later that took into consideration a lot of the single center trials as well and they, if, if you, um, if you look at this, this is incisional hernia out one year again. Er, and they do find a difference if you just look at the basic numbers. So it's 27 out of 1000 versus 51 out of 1000 out of 1000 with a sort of a, a relative risk of two. So that's almost, um, twice as likely is what they're saying, but they actually put it as very low quality evidence. Um Firstly, if you look at it, that's because this um confidence interval is very wide and it includes one. So therefore, er, it's not necessarily statistically significant, it includes one because that means there is no difference and also they felt that quite a few of the trials that they did include, um had some significant flaws with them. Nonetheless, um, this led to a change in the guidelines. So the European and American her societies back a couple of years ago, er released their new updated guidelines, which said that a continuous small bites technique with a slowly absorbable suture such as P DS, er is the technique of choice for elective midline incisions. However, they do clearly say that that is low degree evidence. One thing to point out is um for some time, it's been shown that er looking at the incidence after just one year is inadequate and that the percentage has changed quite si significantly from 1 to 3 years. And therefore it's reasonably well described in previous studies that we really should be looking at the three year outcomes, not the one year outcomes er for hernias. Um And then back in March, uh the three year data was published for this trial, um which I've never known quite how to pronounce, but I say so and it's, they, this is um quite a nice, quite big uh multicenter randomized controlled trial based across Germany and Austria now I was going to go through this in detail but I've cut it down and, uh, but I think it's definitely one that's worth having a look at. It's just elective surgery. Um, they're doing, it's very similar inclusion criteria. Um, they include, they exclude rupture AAA and a few other things, but it's all quite reasonable what they're excl, um, so not rupture AAA, sorry, elective AAA. But it's all quite reasonable what they're in, er, including, and they're looking at three years, um, either clinical or radiological er, hernias and um, I've put this up, um, it's quite busy but basically they did two types of analysis, um, er, an intention to treat and, um, uh I forgot what it's called and um, I think it's, oh, gosh, sorry, prospective, er, patient looking at, so, intention to treat is looking at, um, if you take the number of people at the start of the trial who enrolled in the trial, you base your analysis based on all of them, uh, or you can just look at it um, based on the patients who completed the trial. Um, and the idea being intention to treat is generally a better analysis because it's more, er, similar to a real world um, situations. But what they found is if you look at, for example, the three year data for intent for e any, any intention to treat. Um, again, so, whilst there was an odds ratio of 1.42 if you look at this confidence interval, um It again, it includes one and they find that the P value is not significant. So they concluded that at both one and three years, um in their trial, there was no difference between the two groups. No, I think it was quite a well done trial. Um They used a different stitch that we don't tend to use, uh which has a slight elasticity to it. Um, but it was very, which, which may be relevant. Um, but they were very well, um, set up in their randomization, the way they trained, the way they standardized it across the centers. It's all very clear in the paper and I think it's a very nice paper so they don't find a difference. So I think the jury is honestly, I think the jury is still out really, um, as to whether small bite is actually better. Um, what I wanted to do was talk through this paper, which is, um, from B Js just a, a few months ago. Er, this is the paper that came up in the exam, er, and it's also a, a randomized clinical trial. So, what I really wanted to do is take you through it like you would in the exam. Um, and how you go about presenting it. So generally, um, you start off by, um, so you've just had half an hour to read the paper and they give you highlighters by the way and pens so you could make notes and everything. Um, and then you're gonna go to the exam and they're gonna say, give, give me a, a summary of the paper. And so what you need to start off by doing is not just reading out the title, but you're going to say, you know, this is a randomized clinical trial, um, looking at small bites versus mass closure in open colorectal surgery. It's published in the B Js, uh which has an impact factor of 8.6. Um It's level one B evidence being um a randomized clinical trial. Uh It's published by a group in Turkey which um I'm not familiar with and then you'll say, is it, is it, well, this case clearly, this paper is a prospective trial, but some things you look at will be, you know, retrospective studies. Um You can say at that point, this is an interesting topic at the moment because um there's a lot of interest in small bit closure. The aims of their study are to compare um the two methods of closure. So that sort of thing how you would start off. This is just a reminder of knowing the levels of evidence, um which varies slightly depending on which one you look at. Uh But they will, they will likely ask you that. So it's worth memorizing it then. So I II have to say I got a lot of this from a talk that I heard by Puff take in London. So II can't take them. Um I, this isn't all mine but I think it's a really good, lots of really good things to consider. So then what you do is you go through the methods. Um So you're considering, look for their inclusion criteria, their exclusion criteria, how the subjects were recruited to the trial. Um How did they uh correctly er, ascertain the number of patients they needed in the trial and explain why they did that based on previous previous data, what are their end points? What were they measuring? And how have they measured it? And then specifically for an RCT, how have they randomized it? You know, um Have they done it in a, in a unbiased way or have they given people envelopes so people can just like swap the envelope over it? Is it, has it been done sensibly? How has it been blinded? Have they registered their trial um clearly um in their methods? And um who took the measurements? Were they related to the study that they have a vested interest? Were they blinded or not? Um, consider everything with the po um a way of considering, er, trials which I'll put up on the next slide and then also have a look at the statistics and um are the statistics they use, are they the appropriate tests, er, for example, have they used, um, you know, parametric tests if it's not parametric data? For example. So the trial design here was at a single center. So open label is a fancy way of saying it's not blinded. Er, and it was an RCT, their patient population was, um, open or elective, sorry, um, elective or emergency colorectal cancer surgery in a single center over three years. Um, none of the previous trials have uh, mixed elective and emergency before. Um, the other thing that they did was a bit different is most small bite closure is done with a two OP Ds and they think that that might be affecting the results. So they decide to use a one P DS er, for their small bite as well as for their mask closure so that the needle size doesn't, er, have an effect, which is an interesting idea and then their outcomes are at two years, uh P value less than naught point, naught five, which means that's a 5% chance of something happening by chance to seeing that those results by chance. Um, and they consider several other aspects. Um, anybody, any a SA, they don't have any exclusion of a SA for, um, over 18. Um, and they've got, they've had what they've called a long incision which later they cha characterize. Um, and I'll go through that they exclude people who have had a previous incisional hernia, um, previous hernia repair of any other sort. Um, and uh recent abdominal surgery. So it's a small bit closure. They, they talk through it but not in a huge amount of detail. So they describe the clearance that they need the needle that they're using the way they're doing it with the stitching. But there's no comment on uh the number of consultants in the study, whether other trainees were doing it. Um There's no comment on how everyone was trained to perform it in exactly the same way. So there doesn't seem to be any kind of standardization as far as I can see. Um It comes very obvious when you look at it, uh it's not registered with clinical trials.gov. Um They do do um a power calculation and they randomize in a computerized method 1 to 1. Um and they use the intention to treat analysis and I put it up rather than the protocol analysis. They use parametric tests. Uh They don't do a uh test to check the um spread of the data in order to do that. And personally, I think that they should have used nonparametric tests um which is usually safer to do in this kind of situation. Um They put in, you're always looking out for the consort diagram in a randomized controlled trial that takes you through very clearly the patients that have been included and excluded and why they've been excluded? And do you think those reasons for exclusion are reasonable? And this is important later for when you're looking at this? Um Why do you think that this data is, is um you know, comparable to real life. So the next thing you need to look at um is the demographics table. And in a randomization, the really there should be um an even there shouldn't be any significant differences between the two groups because that's the whole point of randomization. So is to create two equal groups that are comparable for a certain then intervention. Now, the thing that stands out here is if you look at diabetes, there's a significant difference in diabetes between the two groups, um really markedly significant. Um and also a significant difference between patients who've had a previous laparotomy or not, which um you know, in my mind, are, are quite important and then, you know, it's hard to look for absent things. But um I've looked at this three times now to see if I keep missing it, but BM I is not on here. So they haven't anywhere in the paper, you know, er, er discussed the BMIs of their patients, which again, in my mind is actually really important if you're looking at incidal hernia, ros. So then you're moving on to the results and you want to look at how large was the treatment effect? Um and also how, how precise was the estimate of the treatment effects. So, you know, how have they measured it? Like, you know, if, if you measure something just clinically recurrence of a hernia, you know, that's not a very precise way of measuring something, if you're looking at a CT scan and you're saying, is it that, that's more precise. So how large is the effect? And, and how precise was the estimate of the effect? So they put up their, their tables, which are the next thing you'd go straight to when you're at, looking through the paper and they, um, talk about a number of things, how long it takes, how long the suture is. And then really the key part which comes at the bottom, which is the difference in incisional hernia at, at one year and at, um, two years. And they say that there is a significant difference again, what was reasonably clear to me when I looked at it is, yes, they're saying it's significant but there are no confidence intervals. Um, there are no odds of issues, there's nothing there to really make you apart from the p value being significant. If there's no confidence in that, you're losing half the information that you need to really make, um, an accurate, um, decision about whether you think that, that, that this is useful, um, correct data. Um, uh I mean, and the other thing is, you know, if you've got patients who are getting, um, non symptomatic hernia, um, just on ct, you know, actually, if, if they're asymptomatic and they're just very small, um, you know, defects down the line of the hernia, you know, that's, that's very different to having like one large recurrence with a, with a large defect. So, and it's not very clear. Um And then they put in sort of basically a Kaplan Meyer er, plot trying to sort of uh visualize their difference. Um Kaplan Meyer again is something that you'll get asked in the exam. I got asked about these numbers down here. Um uh When they get low, the whole Kaplan Meyer stops being um you can't use it when the numbers drop below 30. Um It's much easier when, you know, you've actually got something reaching 50% because you get a better, better idea of what the difference is. But this is just a, you know, a visualization um which they put in and to be honest, it's not, it's not really that useful. So then you skip down to the conclusion and look up the limitations they've mentioned because they usually will have mentioned their limitations appropriately and you're just looking for little blips here and there in the way they've chosen to, to, to run the trial and do their analysis. Um It's not blinded. Er, so II would say that's a major limitation to try a single center. Er So this is just one group's way of doing things in Turkey. So, um that's got to be taken into consideration significant differences in the diabetes and previous laparotomies between the two groups. And I, I'm not completely convinced they used the, the right tests for their analysis. But so when you look at the conclusions, you, you, you want to summarize what they did, they summarize their findings, um, can they justify the conclusions they're making based on results or have they sort of wildly made claims that don't at all, er, fit with the results they've presented, um, have they compared to the other studies which are out there? Have they set the limitations and most importantly, so if the Typo, can the results be generalized, which is one of the key things and that leads to the most important question which you're going to finish with, which is, will it change your practice? And for me, this paper would not change my practice. But um the trial I presented before, I think that might, so that's um just a quick run through of, of um the, the background and a few useful tips for presenting the paper in the exam. Thank you very much for that analise and uh again, appreciate you under a bit of time pressure, so very well summarized nonetheless. So remember it was a big area of interest and everyone started doing a small bite and then it seems to have petered off as people realized that perhaps it's, it's not a panacea. Um I'm looking at the chat and can't see any questions. Um I know that we've gone on quite a while. So perhaps perhaps the energy to type has, has disappeared from our audience, but I'll, I'll give them a second to see if they, if they do join, I think looking at the stick trial, to me, the things that struck me with that one was the BMI of the patients was, was quite low compared to at least what I experience of another laparotomy. That may be just demographic because it's Scandinavia or the Netherlands, isn't it? The stitch trial? So, but if, if memory serves the, the medium BMIs sort of 20 something, er, rather than, I suspect our medium BM I is, is considerably higher than that for, for most of our midline liposom. Right. Well, I think if there's no further questions and, and given that we have run over time, um, I might close the session there and want to thank, um, all of our speakers, um Mr Tweedle, er, and Elise obviously and, and Megan as well. Um, and, uh, thank you all and hope to see you all for the, the, the next General club. Thank you.