Participants: Dr. James Marcum (Host), David A King
Series Code: BRX
Program Code: BRX00004B
00:01 Welcome back to Bible Rx, Biblical prescriptions!
00:04 We are answering questions on general surgery and
00:08 we are so happy to have Dr. David King,
00:10 a General Surgeon who answers these questions on a daily basis
00:14 Dr. King before break we were talking about
00:17 Laparoscopic surgery and is everyone
00:20 a candidate for laparoscopic surgery?
00:22 How many people getting that verses the old traditional
00:25 where they have to make a large incision?
00:27 Certainly that varies with what
00:29 procedure they are having done.
00:31 As we were speaking before
00:33 the break, we were talking
00:35 about Laparoscopic Cholecystectomy,
00:37 which means having the gall bladder removed
00:39 using a video camera.
00:40 We are to the point now where between 95 and 98
00:44 percent of all gallbladder surgery
00:46 is done laparoscopically.
00:48 Well, that is a good number.
00:49 That has been a tremendous progress from where it started.
00:54 Our next question comes from the Pacific Northwest.
00:57 From June in Oregon.
01:17 Yes that is a very common question.
01:19 Breast masses can vary from a simple cyst to a solid mass.
01:28 Now what is a cyst?
01:29 A cyst is a fluid filled sack.
01:33 The way that is distinguished, even before we do any
01:36 kind of surgery, it is usually with a combination of
01:38 an mammogram and an Ultrasound.
01:40 A mammogram may show it as a mass and the ultrasound
01:43 we will be able to confirm whether that mass is solid
01:46 or cystic, or fluid filled.
01:49 Solid is not good, cystic is better?
01:52 Well, not necessarily.
01:54 Cystic is almost a simple cyst which has no solid
01:58 component to it, it is never cancer essentially.
02:02 Though those can be treated either by observation with
02:05 repeat ultrasounds to make sure there is no change.
02:07 With aspiration, but solid masses are a different story.
02:14 And aspiration of a solid mass is usually not enough to
02:20 make a definitive diagnosis of what it is.
02:22 Certainly when we are taking a biopsy of something,
02:25 our intent is to find out what it is.
02:28 So in a solid mass there are several different
02:33 ways to approach that.
02:34 One is to remove the entire mass.
02:36 If this mass is what we call palpable,
02:38 in other words we can feel it in an exam.
02:41 It can be removed in the operating room just by the
02:47 surgeon, no additional help by a radiologist.
02:50 However if it is the type of a lesion,
02:54 for lack of a better word, and is seen only on
02:56 a mammogram and one that we cannot feel,
02:58 then would require some assistance to find that
03:01 at the time of surgery.
03:02 There is actually a form of biopsy that can be done
03:05 simply by using a mammogram machine and a special
03:10 biopsy needle that can be directed using a mammogram
03:14 machine and computer, that is called
03:16 a Stereotactic Biopsy.
03:18 That uses a very large needle, and certainly the most
03:21 radiologists, when they do this procedure or surgeons,
03:24 will numb the breast before they do that procedure,
03:27 because of the size of the needle.
03:28 Otherwise, minimal pain involved with that.
03:32 That is a nice way to get a diagnosis before
03:36 deciding for or against surgery.
03:38 However in some cases where either you are in
03:41 a small town, and it may not be available,
03:44 or it is a lesion large enough to feel,
03:47 simply going to surgery and taking a biopsy
03:49 of the affected area isn't wrong.
03:52 In most cases when we do a surgical biopsy,
03:56 a breast lump or mass, we take the entire mass.
03:59 That is because when we are doing it surgically,
04:03 there's no particular advantage, unless there is
04:07 very large, to taking a small portion of it.
04:11 So we take the entire thing.
04:12 I know we can't ever speak in specifics,
04:15 but in a general role, let's say you go in
04:17 and take a biopsy.
04:19 At that time would you do anything more,
04:21 or just take the biopsy and be done?
04:22 Usually for breast type disease we will take
04:27 the biopsy and send it to the pathologist
04:32 for a Rapid Test.
04:35 So that is right there where the patient is...
04:38 right there while the patient is asleep.
04:39 This is not always done, but it is done many times.
04:44 That Rapid Test isn't as accurate as the testing they can
04:47 do over a day or two, or even sometimes several days.
04:51 So sometimes we can rely on that Rapid Test,
04:54 but oftentimes we don't and so you will find a
04:57 difference of opinion among surgeons as to whether
04:59 or not they will do that Rapid Test or not
05:01 right at the time of surgery.
05:04 Not every surgeon will do that,
05:06 some surgeons will some surgeons won't.
05:08 I do not think you can call either way of
05:11 doing it as wrong.
05:12 Well I hope that gives June a little bit more
05:15 information, because this is a very scary situation
05:18 to have for females.
05:20 The next question comes from Mac right here in Tennessee.
05:23 And Mac writes:
05:46 Will this is a, Mac has quite a few questions here
05:48 about Inguinal Hernias, does it hurt, how long?
05:51 Questions that everyone should ask if they're going
05:54 to have a hernia...
05:55 Let's talk about what an Inguinal Hernia is?
05:57 An Inguinal Hernia is, well I'll tell you what
06:00 a hernia is in general.
06:01 A hernia, in general, is where organs in one body
06:08 cavity have gone through a defect, or a whole for lack
06:12 of a better word, from that body cavity into another.
06:17 In the instance of an inguinal hernia what happens is
06:21 the bowel or, or fat from the inside of the abdominal
06:25 cavity where it belongs has traveled through what
06:28 we call the inguinal canal, which is in the groin.
06:31 Travels through an opening there that normally
06:35 should not be there.
06:36 It travels through that opening an ends up in that canal,
06:38 or even can travel all the way down that canal into
06:42 the groin area, even down as far as the scrotum.
06:46 When that happens, if the bowel is contained within
06:50 that hernia that can cause obstruction, where stuff
06:54 doesn't go through the bowels like it should.
06:55 That blood supply to the bowel can be pinched off,
06:58 that is called the strangulated hernia and that
07:02 certainly is a bad situation and requires emergency
07:05 surgery in order to relieve that problem.
07:07 Sometimes even remove that portion of the bowel
07:10 if it has been going on too long.
07:11 But basically an inguinal hernia means that, that
07:15 defect is there and as surges we will typically
07:18 recommend that be repaired, mainly because of that
07:22 risk of incarceration which means it gets stuck in
07:25 there or strangulation just like we talked about.
07:28 To repair that hernia, essentially what we are
07:30 doing is patching it.
07:32 If you can visualize maybe the old tube tires that
07:35 we used to have on automobiles a long time ago.
07:38 If the tire were to get a slit in it, but the tube
07:41 remained intact, and you were to blow up that tube
07:44 it would sometimes poke through that little section
07:47 of tire that had a slit in it.
07:49 Well that is essentially what I hernia is doing.
07:51 When the pressure inside your abdominal cavity goes
07:53 up, it causes the hernia to get larger.
07:56 Another example would be a balloon that has
07:58 a weak spot in it.
07:59 If you squeeze it that portion will bulge out.
08:03 So what we do to patch that is the old repair is
08:06 where we would sew up that area, but over the past
08:09 15 to 20 years we have really gotten away from
08:12 just sewing up hernias because the recurrence
08:14 rate was very high because they would come back.
08:16 So now we use mesh, that is a general term for a host
08:21 of different types of materials that we can use to
08:26 patch that hernia defect with.
08:28 It can be plastic it can be vortex like really
08:33 nice raincoats that people wear.
08:34 It can be polyester is one of the newer meshes.
08:37 They don't hurt the body.
08:38 They don't, they are inert to the bodies so
08:39 they doesn't reject them.
08:40 The main reason they were not used early on is
08:44 because the infection risk goes up with those.
08:46 With some of the newer techniques and the newer
08:49 antibiotics we use, that has reduced the risk
08:52 of getting those infections.
08:53 It hasn't eliminated it but it has reduced it to
08:57 the point where it is acceptable risk to be able to
09:01 put that in essentially every patient.
09:03 Mac also wanted to know whether he was going to be
09:06 put to sleep for this?
09:07 Yes that is a good question, not everybody is.
09:09 There are several different ways it can be done.
09:11 Many people do go to sleep with this surgery.
09:14 Although there are other types of anesthetics
09:17 that can be done, even local anesthesia can be
09:19 used for certain types of surgery.
09:20 I bet locally, I don't know, put me to sleep.
09:23 Some people do and it is usually in combination
09:26 with a little sedation so they really aren't
09:29 completely aware of their surroundings,
09:31 but enough so that they are awake through
09:33 the entire surgery.
09:34 Then there is a spinal anesthetic where people can
09:38 be given a numbing agent in the back which will cause
09:41 them to be numb from a certain point in their abdominal
09:44 cavity all the way down to their legs.
09:47 Surgery can be done with no pain that way.
09:49 Now which do you like, I mean it's the per person?
09:51 How do you choose?
09:52 It is somewhat based on the person.
09:55 I generally will leave that up to a decision between
09:59 them and their anesthesiologist.
10:00 I have noticed that there is a fairly significant
10:02 variation in how that is done regionally.
10:05 I have practiced in several different locations,
10:07 and one location people tend to prefer one way to
10:10 do it and in another location they may prefer another.
10:12 On the average how long before Mac is
10:14 back driving his truck?
10:18 If he doesn't do a lot of heavy lifting in driving his
10:21 truck, some truck drivers may help unload their trucks.
10:25 But in a situation where he will not be lifting more
10:28 than say twenty five pounds, some people can go back
10:31 to work as early two weeks.
10:32 There is a significant variation in that though.
10:37 I generally will tell people don't expect to go back
10:42 sooner than that.
10:43 But anywhere between two and four weeks is typical.
10:47 I get this question occasionally.
10:49 Do you think people that lift heavy have more
10:50 hernias than don't?
10:51 You always here that grunting and straining,
10:54 do you think they have more hernias
10:55 than the general population?
10:57 Probably, though I do not know if we have any
11:00 good studies to prove that.
11:02 What we know though is that it is probably a
11:06 combination of activity and either genetics or
11:10 something in their formation when they're a fetus.
11:14 It happens so that one particular area of the body
11:18 has a weak spot.
11:19 So the combination of that and activity can cause
11:22 hernias, though we do see incidence of hernias
11:25 in people who do no heavy lifting.
11:28 So it can occur from anything that causes
11:32 increased abdominal pressure.
11:33 People that have a chronic cough,
11:34 people who are chronically constipated,
11:37 people who have problems urinating.
11:39 All of them can develop hernias for that strain on
11:41 the abdominal cavity.
11:42 Would you say the groin hernias are the most common?
11:44 Because I know people that have had other surgery
11:45 sometimes they have hernias too.
11:50 Yes inguinal hernias, or groin hernias are the
11:52 most common hernias, yes.
11:54 Umbilical hernias probably the next common and then
11:57 what we call incisional hernias, like what you are
12:01 talking about after surgery are common as well.
12:04 Then there is a long list of other types of more
12:07 obscure hernias which can occur.
12:08 Well our next question is from North Dakota
12:12 and Alice writes in and says:
12:33 What's reasonable?
12:34 Sure that is a great question.
12:35 I think you will probably find a significant number
12:40 of answers to those questions on the Internet.
12:42 I would just say from my own personal opinion what
12:45 I think it is important to ask.
12:46 Number one I think you need to ask how the
12:51 procedure is going to be performed?
12:52 How the entire process is going to take place?
12:56 Will it be in the hospital, or a surgery center?
12:59 Get an understanding of what it is they are actually
13:02 going to do and have them explain to you what they
13:05 are going to remove, if they are removing something.
13:08 What exact steps that may take in order to do this?
13:10 As far as asking how many procedures the
13:13 surgeon has done...
13:14 Now what if they just starting their career
13:16 and are a great surgeon?
13:17 You can do a thousand and one of these and 500 are bad who cares?
13:20 What I think maybe a better question to ask.
13:24 How comfortable are you with this procedure?
13:28 How common is this procedure done?
13:30 There has actually been a number of studies done
13:34 assessing if volume of a particular surgeon makes a big
13:38 difference in the outcome.
13:40 What they found in most of those studies was that
13:43 actually it is not as much volume of that particular
13:46 surgeon as the volume of those particulars procedures
13:49 done in the hospital where they are doing them,
13:51 or the facility that they are doing it in.
13:52 The hospital releases who's good and who's not?
13:55 That's right! Most surgeons who are in the community
13:59 have had training which we deemed them to be competent
14:02 by having that training to do
14:04 that particular procedure.
14:06 So asking them the number of procedures may give
14:09 you a number but being able to interpret that as
14:12 something that would be helpful to you is very
14:15 hard to pin that down.
14:16 I think asking if they're comfortable with the procedure,
14:20 asking how many of these procedures are done to determine
14:23 whether or not this is a common condition,
14:24 a common operation does give you some indication of what the
14:29 risk of problems occurring from it are,
14:31 because we know that rare surgeries typically have and
14:34 carry a higher complication rate.
14:37 That's good, well I hope that answers Alice's question.
14:39 You know in thinking about general surgery,
14:41 the few times I have been in the operating
14:43 room and participated.
14:44 It seems like it's almost a spiritual.
14:46 When the patient goes to sleep and you are there and
14:50 open up and see the organs and then are seeing
14:54 what God has made.
14:55 It seems almost like a spiritual.
14:57 Do you feel once before and after you have been inside
15:00 of a person, does your relationship change with them?
15:03 It seems like it's very spiritual.
15:05 How do you work that into your practice?
15:09 Yes, surgery is a spiritual experience,
15:12 both for the patient and the surgeon.
15:14 With my patients, I try to establish a rapport with them
15:19 openly and before surgery.
15:20 Most of my patients I pray with before surgery and that
15:25 develops a rapport with them and a feeling of
15:28 confidence and caring and believe it or not it has
15:33 been scientifically studied.
15:35 Yes it has been.
15:36 It has shown to be of benefit.
15:37 Even in situations where neither the patient nor the
15:40 surgeon were a believer, that is still benefited them.
15:45 So initially, even before the operation takes place,
15:48 establishing that spiritual relationship is important.
15:52 As you mentioned through the operation and afterwards
15:56 as you see that patient recovering,
15:57 there is a bond that you form with them that
15:59 is something you carry your whole life.
16:03 Sure we have had other surgeons on Bible RX,
16:09 have you seen miracles happen, things when you are
16:11 in a body, that you cannot explain that God does?
16:13 Many, many, often.
16:16 God often works in that way.
16:18 You know we have a few more questions here,
16:20 but I'm afraid we are going to have to save
16:22 them for next time, Dr. King.
16:23 Thank you for being with us and given
16:25 us your insights.
16:26 I am sure people from all over, we have people that
16:28 watch from Australia and New Zealand and Canada
16:29 and the United States.
16:31 I'm glad that they watch.
16:33 We are out of time here, but if you would like to be
16:36 a part of Bible RX, you can give us a letter or
16:39 you can get us on the e- mail, our I address is:
16:49 or if you have a computer we can be reached
16:52 on the web at:
16:55 We would love to have your questions and specifically
16:59 if you have general surgery concerns,
17:00 we would like to have Dr. King on again and will try
17:03 to answer your questions.
17:04 It's always reassuring, and I think part of
17:07 the treatment is education.
17:09 as you become more assured of what is going on in your
17:12 life and you have more information it lowers some
17:14 of those stress chemicals.
17:16 We're not to thank you for joining us on Bible
17:18 Prescriptions today as we've talked about
17:20 General Surgery with Dr. David King.
17:23 Thank you for joining us!