Dear Hernia enthusiasts,
This is Gaurav Kulkarni and I am a post FRCS, Abdominal Wall Fellow at Broomfield hospital in Essex, UK. I attended the EHC congress in Manchester 2022 and got familiarised with the work done by Professor Miguel Angel Garcia-Urena at Madrid and met him at subsequent events. I felt I would be able to learn a lot from visiting him and interacting with his team.
I was very fortunate to be bestowed the the EHS Travelling Fellowship Grant at the Barcelona Congress. This provided me the opportunity to fund my Madrid visit with Professor Garcia-Urena for the last six days of September 2023. This was the best way to observe a leading expert in the world of abdominal wall surgery and get a ringside view to learn from the maestro.
He put together an action-packed week for me to fit in as much learning as possible. We had a full day of outpatient clinic with more than 20 patients. Some were post- Complex abdominal wall reconstruction performed by their team as well as those seen as new patients. Since I did not know Spanish much, I was apprehensive about this clinic as I would not be able to comprehend the interactions. However, Prof Garcia-Urena came up with a plan where we would discuss about the next patient and go over prior history and scans in English before the patient entered the room and that immensely helped me understand it all. Prof was kind enough to inform every patient who I was, and ensured they were comfortable of my involvement in their care. Midway through the clinic we had a lady who was especially happy with her surgery and brought in a gift of home-made muffins which provided us with the much-needed lunch in middle of a busy clinic!
The second day began bright and early with me heading out to the Puerto de Hierro hospital at Majadahonda, a different area of Madrid. I spent this day with Dr Javier Lopez-Monclus including theatre with him and laparoscopic proctoring. He was extremely welcoming and I observed a wide range of MIS approaches to primary and recurrent groin and ventral hernias. Dr Monclus shared with me his step-wise approach to eTEP as well as tips in tricks of safe endoscopic surgery in retro-rectus space including e-TEP for spigelian hernia. I have been a TAPP surgeon for my laparoscopic groin hernias and attended courses before in the e-TEP approach. But having a direct proctoring cleared my doubts and apprehensions about this technique and I feel confident now to utilise it for the right indications in my practice. He was also kind enough to drop me back on his way home.
I spent a large part of third day listening to lectures by Prof Garcia-Urena and seeing the presentations prepared and presented by the entire Madrid team prior to a busy three operative days ahead. I also got some time off later in the day and was able to visit the Santiago Bernabeau stadium which was highly recommended by Prof as he is a true and passionate supporter of Spanish football.
On day 4, We had complex abdominal wall surgeries for recurrent hernia which included midline and lateral hernia in same patient involving prior onlay mesh. This involved complete dissection through the prior mesh and in the retrorectus plane, adhesiolysis and full release of the left sided transversus abdominis muscle by the Madrid technique. I scrubbed and assisted Prof in this case and was able to see how he dissects the peritoneum much medial to and underneath where the transversus muscle fibers are present and that way the transection line doesn’t involve cutting muscle. Also, I learnt how to change the plane of dissection into the pre transversalis plane to widely cover sub xiphoid or subcostal defects underneath the fascia diaphragmatica. It was nice to see his technique of Taco configuration for meshes in lateral hernias. I built up on this learning the next day when we had two more cases for a lateral post nephrectomy and renal transplant hernia and another midline swiss cheese hernia which I scrubbed in as well. There was also a AWR hernia masterclass arranged and I was able to attend the lectures where they provided a Spanish and English presentation for my benefit in addition to Spanish surgeons attending there.
It was also good to spend some time with the Madrid team outside of the work environment when we all met for dinner at a very nice restaurant in Madrid and try authentic Spanish cuisine, discussing sports and plans for the upcoming hernia conferences including the 2024 EHS congress in Prague.
After a full week of clinical work, it was topped off on the Saturday with a detail-oriented Cadaveric AWR dissection workshop at the University anatomy hall as an icing on the cake. The team had arranged four frozen cadavers with support of Industry and it was very heartening to be able to perform bilateral dissections by the Madrid APPROACH. I also witnessed Prof Garci-Urena perform a full medio-visceral rotation dissection to depict characteristics of posterior abdominal wall to all the attendees and see anatomy related to the undersurface of the diaphragm like never before.
During my time in Madrid I had also the chance to know Prof. Luis Blazquez and Dr Robin. I would like to thank them for the time they have dedicated to my visit. I’m convinced that over the next few months, this experience will become the cornerstone of how I operate and manage my hernia patients. I can’t emphasize enough how professional the Madrid team is, and how humble and accommodating they all are despite the high skill level and volume which they operate. I encourage everyone interested in abdominal wall to look at their extremely educational YouTube channel Herniatoday !
This visit has been one of the key highlights of my career so far and I thank EHS for the support and Grant.
Gaurav Kulkarni MBBS, FRCS (Edinburgh), MBA.