Excision of Suspected Chronic Infected Suture Sinus

CHAPTER 1

Hi, my name is Eric Pauli. I'm a Professor of Surgery at the Penn State Hershey Medical Center, in Hershey, Pennsylvania. Today we're gonna do a relatively common procedure, believe it or not, although it's not the most technically challenging thing, which is basically the excision of what we believe to be a chronic infected suture sinus. We see this with some frequency. Anytime a foreign body is placed in the abdominal wall, it can result in an infection. Oftentimes, suture materials get infected after procedures, whether that's a simple fascial closure, or hernia repair procedure. And so a handful of times a year, we'll meet somebody who has a piece of suture in their abdominal wall that's chronically infected, and needs to be removed. Our patient today is a 65-year-old who I met about two years ago. In 2010, she underwent a left-sided DIEP flap for reconstruction of a breast malignancy. At that time, her main complaint was a bulge in the left lower quadrant. She said that she had been riding an exercise bicycle, felt a sudden pain and a pop, and had a bulge in the lower abdomen. And she was referred to me for evaluation of what people thought was likely gonna be a hernia, and I thought it was gonna be a hernia as well. We scanned her and she did have multiple midline incisional hernias, and she had a bulge, and a posterior sheath defect where the DIEP flap was taken. But those weren't the problem. In the immediate suprapubic region, she had a fluid collection and some inflammation and some stranding. And so our thought at the time was that this was likely some traumatic event. Maybe she had pulled one of the permanent sutures that was used to affix her mesh to the abdominal wall, had given herself a hematoma, and things would resolve. We followed her expectantly, and she seemingly did fine. But now, two years later, after I first met her, she came back to see me. And she said that she had had ongoing issues with pain in that area. The area eventually was less swollen, but she'd had drainage from the abdominal wall. And when we met her in clinic, she had an area that was open, and partly scabbed over. Repeat imaging demonstrated what looks like a small fluid collection that tracks down to the level of the fascia. And so rethinking the initial story, this may have been the initial presentation of a chronic suture infection. And so I'll show you the two CT scans that we have, which kind of demonstrate the progression of this area over the course of time. But our goal today is to basically excise the entire area, head all the way down to the fascia, remove anything that looks like it may be suture material, and also to confirm that this does not track down to the corner, or the end of the mesh that's in place, and that this isn't a very suspicious or low-grade mesh infection as well. This is a CT scan from our patient today. Again, in 2010, she underwent a left-sided DIEP flap that was reconstructed with mesh. And in the fall of 2022, I met her when she developed a bulge in her left inguinal region after riding an exercise bike. So this is the initial scan that I met her with from 2023, where there is a bulge in the abdominal wall here from a hernia. She has another hernia in the midline, so multiple midline hernias in the upper abdomen. And then obviously, you can see the consequence of the DIEP flap, with fat in the posterior sheath, and a very bulgy muscle down below. There's posterior sheath breakdown here. The area that she had her primary issues though, is right here. So this is when I first met her. There's stranding and inflammation in the subcutaneous tissues. And based off of that story, and the fact that she said this happened after trauma, our initial thought was that she had maybe pulled one of the Ti-Cron stitches that was being used to hold the mesh in place, and given herself a small abdominal wall hematoma. I observed her for several months, and for the most part, the area went away. Unfortunately, basically a year and a half after I first met her, and had these images, you know, she returns. Actually it's almost two years after I first met her she returns, and so here's her current scan. The issue sort of remains. She kinda always had a small area of bulging in the lower abdomen, but it had actually drained through the skin surface. And so you can now see that this, the lower portion of this cavity, now communicates to the skin surface right here. There's a small amount of stuff collected underneath the skin. And then this area does track upward, following upward toward the level of the anterior abdominal wall fascia in this region. And so our concern is that if she did pull a stitch, and that area got infected, that this represents a suture abscess or some abdominal wall foreign body. And so we will cut down on this area today, and remove this entire tract, all the way up to and including any fascia that needs to be removed.

CHAPTER 2

I re-looked at her scan. Yeah. And I initially thought it tracked kind of upward. It kinda goes, like... You can see the skin indent. There's a little bit of an abscess here, and then it kind of goes like, it's within two centimeters of this spot, that it goes slightly lateral. So I'm not sure if it's like a transfascial stitch or what. It kind of heads that direction. So the goal is to find the thing that's at the base of this. And the story is very classic for an infected suture sinus. Yes. It drains, scabs over, I'm fine for a while, then it drains and scabs over, and then I'm fine for a while. And sometimes you can just dig it out in clinic. Like if they're draining, you just reach a little grasper in there, and you kinda yank, and a bunch of suture comes out. But this, she has not come to clinic where it's been kind of actively draining. And sometimes again, when you get a scan and you can see that it tracks some direction, like digging it out in clinic is not always the easiest thing to do.

CHAPTER 3

[No Dialogue.]

CHAPTER 4

Would you guys have a culture swab available as well? I have it. Awesome. Hold off. I just wanna make sure we have one. And then we'll take an Allis. Nice.

CHAPTER 5

All right, yeah, keep going. Just get through that stuff. So we're gonna, we're ellipsing the whole skin and scar out. This is less about the cosmesis of how this is gonna appear, and more about the, we wanna track this thing all the way down to where it goes. And also that stuff looks pretty nasty anyways. And then we'll get a little Allis on it, and we'll kind of lift it up and grab it and we'll kind of track it down. Again, and this is always a bit easier, at least to find where they start when people are actively infected. Because when it's actively infected, you just follow the pus, as they say on that Harry Potter movie, "Follow the spiders." Okay, let me see what we can find. I'll take a snap. Again, just to keep in mind that it kinda goes both inferior and superior from this spot, but mostly it goes a bit lateral, okay? Well, let's see what we can find. A little bit of fluid there from the local. What kind of sutures do you think this is more common with? What kind of suture material is likely to have this problem? What are your thoughts? Braided. Braided or what we call multi-filament suture. Yeah, why is that? 'Cause there's multiple filaments and like makes crevices that bacteria like. Yeah, bacteria like 'em. But I mean like, what is that? I mean, so, okay, so bacteria. Bacteria, like lots of things, but like your body can usually get rid of them, right? Is there a hole? Can a mesh or a suture have a hole so small that a bacteria can get in? But it goes kind of that direction, I think. Mm hmm. That a bacteria can get in, but a macrophage can't? Are you saying that bacteria, I'll take a right angle. Are you saying that bacteria are smaller than macrophages? I don't think so. You're not saying that? No. Bacteria and macrophages are the same size? I think it's more so about the environment, making little pockets, rather than like not being able to access it. What can bacteria make to allow them to hide? Virulence factors? Just lop that off. Capsules? They make a...? A glycoprotein? Yeah, does that have a name? What is it called? Yeah. A film. Yeah, a biofilm. That's exactly right. So bacteria can make, some bacteria make a biofilm. And a biofilm is proteins and glycosaminoglycans that allow it to hide and escape phagocytosis. I don't think that's anything. That might be something. Yeah, again, there's a little tract that heads that direction toward the fascia. And remember that her fascia's gonna be, I mean she has normal fascia, but because of the TRAM, she's gonna be - I'll take a DeBakey, please. She's gonna be missing some elements of what we would consider to be normal. And then there was, there was an abscess here at one point in the recent past in October, in December that kind of drained out. And so some of this is just the residual, you know, abscess cavity. We'll keep working our way. Can I have a small like Senn. Working our way down. Yep, let's go to the bottom here. Give me a Senn instead, please. I don't have the Senn, I have the S. You can also just grab with a toothed pickup. Just grab the skinners there. But bacteria are smaller than macrophages as well, okay? Yes. And so there is a size limit to which a bacteria can get in somewhere and a macrophage can't and it's around 10 microns. Okay. And so if the space between things is less than 10 microns, then you may have a problem with the ability to clear a bacteria if it gets in there. Okay. But obviously the biofilm, you know, increases that likelihood as well. Okay, we're just gonna keep this is, this mostly goes straight down. We're just gonna keep working our way straight down around that, okay? We're just gonna keep working our way down. We're just gonna follow it all the way down until we get to the fascia. Easy on that upward pull, don't rip it. You want another Allis? Nice. And again, when you see, so look, that's anterior abdominal wall fascia right there, okay? And so we're just gonna work, let's just work around that. Let's get down to an area where we can sort of see some normal, we'll get the normal fat out of the way. We'll clear. This is just a layer of scar and rind from around it that has formed over the course of this being infected and then draining multiple times. Yep, okay. And we'll get down. That's gonna be probably some of the anterior fascia getting tinted up there a little bit. She does not have a lot of subcu fat here and so, we'll we don't wanna make holes in the fascia. Let's just, let's just use that as our starting point. Let's, yeah, I like that. Let's just work our way around. Okay, I think that that's normal. I don't, I'm not sure. No, I think that's probably just... I think it's nothing. Scar and other stuff. Yep. Let's, let's, let's go through that and if we see a bunch of junkie stuff come out, then we'll say, oh, that may have been part of the tract and we can always, I can also just pick it apart here. No, there's nothing in there. But if we decide that we think that there is, we can always just trace it from that spot. But I think that again, as you, as you lift up, to me this looks like it's mostly going just down that direction. What other sutures might be more likely to do this? 'Cause like Vicryl suture is multifilament and I've never ever pulled out a Vicryl abscess from anybody. Do you mean like in terms of like permanent versus non-permanent? Yeah, permanent versus absorbable. So Vicryl is, is permanent or absorbable? It's permanent. It's absorbable. Absorbable. It's absorbable, which is why I've never seen an abscess with it, okay? It goes away in about six weeks. Permanent. Permanent is permanent. Permanent suture doesn't do the thing that you think it does in your brain. because you are a third-year student, you think permanent suture, we put it there because we want things held together permanently and that's what permanent suture does. But the problem with permanent suture is that it loses almost all, all of its tensile strength. Yeah. Like it's still there as a structure, but it's lost all of its tensile strength. And so you've got a structure there permanently not doing anything. So again, we're just continuing to follow this down. Yeah. Sometimes you can actually suddenly feel a foreign body and I don't really feel anything yet. Let's just keep working down to take that little retractor again. Let's just clear this bottom edge, which appears to be mostly just kind of normal fat. We'll just keep working this direction. Yeah. It loses all of its integrity to maintain tension. All the tensile strength is gone, but yet it, it's still there. And so there's really like, you know what, what would you, what would you need that for? Like what, what purpose does that serve? And the answer is really like not, not a whole lot, okay? And so there are very few things where I think people would say, oh you should definitely hold this together with, like you must have permanent suture. There are very few uses. And like in the world of general surgery, you know, holding, holding a mesh in place to the abdominal wall that's gonna get incorporated on its own and be there permanently like that doesn't make a ton of sense. And so this is, I mean the stitch here is from some part of her TRAM flap. Either the fascial closure or the mesh closure. And again, it probably doesn't need to be here permanently. Do clips have any like increased rate of infection? Like surgical clips? Like for like a cholecystectomy for example or something like that? Yeah. Well I mean not really because you know, there's no, there's no, there's no major foreign, like the foreign body response to metal is very different. Yeah it's very different than the foreign body response to... Like if she has some... The suture. Epigastric like vascular so... Correct. There are some little clips there. Yep, I'll take a DeBakey. Yep, yeah you're correct. If you look at the CAT scan, she has a bunch of clips there from where they divide, you know, divided the muscle to do her TRAM flap. And also we should also point out that this patient has multiple hernias as well, right? Which we are doing what with? Nothing. Nothing. Because? 'Cause of infection spread from this. Well because... The same time. Well right, so number one she has some active infection. Yeah. And so like going in and doing a hernia repair at the same time that you have an active abdominal wall infection that can easily be treated with the procedure we're doing now, which is kind of a more minor outpatient thing. I can actually see underneath all of this. So this whole layer here. Scarpa's. I think it's just scarpa's. Right, that's anterior abdominal wall fascia there. So anything above that can't be it. This is probably just a very well developed Scarpa's layer, which is what we would expect at that location. And again, I don't think there's anything in there. So I would just take it like right about here and as you come through it, we'll make sure we're not traversing some sort of a sinus tract. I don't see anything there. Let's go back here now and let's just keep working this direction. Okay, we'll lift it up and we just have to understand that on the backside that's stuck to Scarpa's, okay? What if we get this up and we don't identify any foreign body in it, what do we do? I don't know. Just debride. Keep, keep, keep looking, I think. Keep looking. Keep looking is an okay answer. Like what? Okay. Let's just look somewhere else. Keep looking. Yep, for sure, keep looking somewhere else. And then what if you still don't find it? Well if you've done your due diligence and you're pretty sure that you've followed the tract down and you don't see anything in it, you send what you removed. And guess what? Oftentimes when the pathology guys slice this open, pathology guys or gals, they find something and they say, hey, there was a thing in there. Richardson. Are you aware of it? And we say, yeah. So then I think we're gonna keep kind of heading like down. I wanna say it's kind of down this direction, okay? We're gonna go... Yep. Again, I'm just kind of feeling the direction that I think it's going. I think it kind of heads this a direction here. So this is again, I think some Scarpa's layer of stuff. It's pretty heavily, this is like heavily scarred. Er. Yep, go ahead. Again as you come across it, we'll look and see. Do we see any tracts or sinuses? Nope, nothing. Okay. Nothing in there. Let's go that direction. This is the direction where the abscess actually was on the scan. It kind of went medial and slightly inferior from where the skin opening actually was. DeBakey got it. We found the blood supply to it. And we're gonna have to just work our way across this now and make sure that we think we're as deep as we need to be. Part of the reason why it's nice when there's actually an active infection or the sinus is open is you can stick a little probe right down in the tract and just kind of follow your metal probe all the way down to where you think you need to be. But no such luck, this closed over on its own. I oftentimes won't treat these folks with antibiotics because, I'll take it a DeBakey, 'cause I actually want it to be, you know, kind of draining at the time that we do it. These are little superficial epigastric vessels. I'll take another DeBakey. Do you guys have ties or clips or anything like that? It's okay if you don't. I mean it's in the superficial skin so it should be okay. Maybe not. We'll take a right angle. We'll take a little Vicryl tie. Pull hard. Okay, we'll tie it up. Just a free tie. You can cut the needle off. So is the goal to locate the abscess first and then look for like tracts and things coming off of it? Well, I mean usually when these have formed and gone away multiple times as hers has, it's usually got it's, it's like a fistula, which is a communication between an epithelialized organ and another epithelialized organ. Think about like an enterocutaneous fistula. You know, usually if they're opening and closing as some of them can, they follow the same way out each time. Okay. Once it finds its way out once, it just follows that way out. And so most of the time when you see a sinus like this, it's the main sinus. It's been draining from the same spot repeatedly. And so typically when you find this, you just kind of work your way down and you eventually get down to where the problem's coming from. Again, this all feels very soft to me now, Ben.

CHAPTER 6

I don't feel anything else that's obvious in here. This is gonna be Scarpa's. We'll have to take a brief look a little bit deeper once we get through this and make sure there's nothing at the level of the fascia that we're missing. But I haven't seen us go through a tract or a sinus yet. That looks like some pretty benign-appearing fat. Yep, that's just Scarpa's and scar. This is just fat and scar. Okay, so that'll go as part of the specimen. What do we call that? Label it as suture sinus. Suture sinus. Yep. We'll take some smaller retractors now.

CHAPTER 7

So there's your external oblique. Take a look in here. Okay, I'll take another Army-Navy. Uh-huh. Alright, so how do we know that that's the external oblique muscle? 'Cause it's underneath Scarpa's fascia. Grab, grab this guy right here. So it's under Scarpa's. And then does the external oblique, do the fibers go a specific direction? They go one way and the internal go the opposite way. Okay, so which way do the external go? Oh. Hands in pockets, hands in pockets. Hands in pockets. Okay, so hands in pockets. Okay. So those fibers go hands in pockets. Yep. And so that's the external oblique. And so that's the anterior most layer of the abdominal wall. That's the muscular layer. Yep. Permanent. And so now all we're gonna do is like, we're literally just gonna feel. Like what do we feel? Do we feel anything in there that feels foreign or domestic? There's a little something right there. We're gonna have to investigate that. It may be your tie that I'm feeling. It looks like it. Yep. Right here is a thing. Would you be able to check my? Yeah. I see what you're saying. Yeah, right there on the external oblique fascia. And again that kind of goes the direction that we were thinking about. So let's, we'll just, just take a look in here and see what we see. Relax for one second. Again sometimes it's just, you know, I mean we buzzed that little vessel that was there, but I feel like right there is is the spot. Take some retractors now. Get another little retractor there. Gonna give you that guy to hang onto there. Hang on here. This is all Scarpa's here. Yeah, let me take this and come underneath that. Yeah. Okay, let's take a look up here. Is that your tie? That's your tie right there. So the only foreign body that I feel is one that we literally just put there. We also used a piece of Vicryl so that even if it were to get infected, because this is, you know, we think that this is an infected field... We aren't gonna lose a lot of sleep over the fact that we left a stitch in here. Can you hold this one here and then Ben, you're gonna handle this one here. I'll take a snap. Again I'm just, where I'm choosing to do a little bit of extra digging is all places where on the scan we said, "Hey, it kind of heads this direction or that direction, right?" We know that from the skin surface, it kind of headed upward, that's Scarpa's there. And again, because it's a permanent suture you're looking for, there's usually a little cavity around it and a reaction. So when they're obvious, they're obvious. And when they're not, they're not. And again, there's nothing too obvious here. I will take a right angle. Stay superficial on that. Uh-huh, good. Keep going through all that. Yep. That's that scar. Yep, good. Okay, fine. This is kind of the area that I wanna make sure that we investigate more thoroughly. So come through that. Yep, okay, fine. Now let's take a look at that. You have a Rich for me? Actually that's gonna be too large. We're okay. Yeah, maybe there's something there. Go ahead and take this from my left hand please. That you can go through. Nope. And again, her scar from the TRAM is obviously up top there and so you just wanna make sure that you're not feeling like, you know, sometimes this is the tip of an iceberg and it's actually a mesh infection and it's actually tracking up to the mesh. But I don't, I don't feel anything up there at all. It feels all totally normal and fine. And so I think that, like we can take this with us. Yeah. This little thing can go with us here. But I don't think there's anything in it. A little more for the specimen. Okay. Okay, there you go. Alright, take everything out. We'll do one last quick feel around here. That's a little perforator that we went through earlier right there. You can actually see it. I don't think that that is a manmade structure. You see that coming through, there's a split in the... It's a little perforating vessel coming through a split in the muscle there. Yeah. Nothing, nothing. I don't feel anything else obvious. You wanna give it a quick feel there as well? So the expectation is obviously if you were thorough in kind of how you grab that, that the foreign body is in there, I don't feel obligated to lift it open and feel. And then the question is, what do you wanna do with this? With the wound? We'll take some irrigation. I'd close it in layers. I think it's okay. I don't think we need to pack it open. You wanna just close it loosely with a couple nylons at the skin? Yeah, we can do that. That sounds great. So sometimes these are super satisfying and you go aha, like there it is. There it's, yeah. Yep. We could also close it and then leave a like a quarter-inch into it too. That's okay. Have her take it out in a couple days. Yeah. I'm okay with that. Yep. Okay. Great.

CHAPTER 8

2-0, 3-0, 4-0. And then we'll take a little bit of some quarter-inch Nu Gauze. 2-0 Vicryl, 3-0 Vicryl, 4-0 Monocryl. I'm not sure, you're gonna try and close Scarpas with the 2-0 maybe? Yeah. Thank you. So that's Scarpa's layer getting put back together, and again, you know where we're working, I mean we're essentially over her inguinal canal, right? Here's her ASIS, her pubic cubicle is right here. And so like some of this putting back together, you can leave a little bit of a tail. Yep. I'm sorry. That's okay. It's gonna be a little bit like, we'll take a 3-0 now. Put a couple... Adsons? So when you talk about where to close, the question is like not the superficial, it's more so like what layers of fascia and muscle you're gonna close, so it can drain? Well yeah, I mean normally we wouldn't have any concerns about what layers to close. We'd just close a bunch of layers, right? Yes. Again, if this was an inguinal hernia that we had just done, we'd closed the external oblique, then we'd close Scarpa's, and we'd close the skin. Usually in three layers is how most people do it. Would you like a tail for this one? That's okay. Yep. The consideration here though is, you know, theoretically this was, this is an infected wound, right? There was a suture sinus there and we assume that somewhere in the middle of that is a little infected foreign body. And so we're, you know, we're kind of, we're taking a little bit of a risk here by closing a wound. We could leave this open and just pack the thing open. Okay. And it would be fine. She would not get infected. But also there's a fair bit of wound packing involved in that and the cosmesis of that is not gonna be super nice. And so you gotta think about those considerations as well. The other option then is to do what we're doing, which is a couple loose stitches here and there to get the layers roughly together. We didn't officially seal that lower layer, like okay these are all interrupted sutures. And so if you're a little bit of puss and you are accumulating down below, you'll find your way out eventually. Okay. But also what we're gonna do is we're gonna kind of just put a couple stitches in the skin loosely and we're gonna pack in the middle. We'll leave a little wick behind. Okay. And she'll take it out in like 48 hours. That'll let anything kind of junky drain out. You want put any 4-0's in? I was gonna put it in and suture the 4-0's around it. I'm okay with that. Yep. That's probably good. Scissors. Want cut that, like that. Just here? Yeah. 4-0 please. Yeah, like that. Yeah. Yeah. I'll just keep that open. There you go. Yep, start right there. Just don't sew it in place. That'd be exciting. That'd be a great call in 48 hours. Yes. So the goal here is obviously wound care that is relatively simple for the patient and doesn't require her to do a whole lot. You can cut that one. Yeah, there you go. If you were to leave it completely open and just pack, she would have to in theory, change the packing multiple times a day. Is that correct? Yeah, if we decided to do, yeah, have her change it and do sort of, you know, wet to dry packing, you know, twice a day. Yep, you gotta stick some gauze in there and get it in and you know, again it's, you look at the wound you say, oh it's a small wound. That doesn't sound like it would be particularly difficult to do, but you know, like not everybody is as used to wound packing as you might be. And you know what, what makes one person squeamish is not what makes another person squeamish and... True, yeah. You know, obviously some people have help and some people don't. Some wounds the patient can't see. I mean she would be able to see this, it wouldn't be too hard. But like you can obviously understand that there are some wounds that like... Can't reach. Can't reach, right? You can't get there from here. And so if you want the wound to be effectively packed, then they need a visiting nurse. So there's a, you know, combination of factors that go into should we be closing this or should we be leaving this open? This is not particularly like this was, if there was pus rolling outta the abdominal wall, that'd be a very different story. We wouldn't be closing this. And while I assume that there are some bacteria in that thing that we just took out because it was a suture sinus, I'm not super excited about the level of contamination here. Okay? Dermabond? No, we're gonna leave it like this. Just a little airstrip. Do you want any more local? Yeah, we'll give some more local. You are gonna cut that right at the skin level, but no skin biopsies. Okay. Got some more local? We're finishing up, we're just gonna put a little more local and then we're done. Thanks. Yep. A little neurectomy we did there probably gonna help with the pain in this area as well. We will take a little more local at the, you got 30 total? Awesome. Give him some more. So see he's aspirating there because there's these superficial epigastric veins here. He wants to make sure he is not in 'em before he injects. Yep. Injects. Okay. That's... Wonderful. Okay, that's all 30. Okay. We'll take a dry gauze. Or you gotta dry gauze dressing for us? A little airstrip.

CHAPTER 9

So the procedure went fine. You know, these are generally pretty straightforward procedures. We did not find an obvious suture in the area that we are working on, but we also didn't really disrupt the tract that was there. So in the specimen that we sent down to pathology, we'll have to wait and see if they find a little bit of a foreign body in that tract. I think importantly, if you're doing this and you're not finding an obvious foreign body, you've gotta make sure that you're not missing something around. And so you saw us spend a few minutes searching to make sure we're not missing another area. I think additionally, knowing that this patient has mesh in an onlay position in the abdominal wall, you wanna make sure there's not obvious or exposed mesh and there was not in this particular case. So we'll see what the pathology shows at a later date. The area will be packed, it'll hopefully close up. And then my ultimate goal for this patient is to fix her hernias, which are now bothersome and hopefully do it without an active draining sinus. We had a student with us during the procedure today. We're an academic teaching hospital and so we have students with us pretty regularly. You know, when I, when I'm talking with students in the OR, there's a variety of things that we're trying to get them to understand. Some of it is basic anatomy, some of it is an understanding of material sciences. You know, a lot of it is just the thought process of being a surgeon. You know, we quiz people not to make them feel stupid, but to help them understand that they actually know a lot more than they think that they know. And so a lot of the questions were just for her to explore her own knowledge, think about where there's gaps in the knowledge and again, like it's, this is low pressure, you know, quizzing to help people understand what we're doing. You know, that procedure does, you know, doesn't have a lot of technical steps. We're mostly just removing what we think is an infected suture sinus. But, you know, we'll ask people about the steps of a surgery or why we're doing specific parts. If you are in an operating room and somebody is asking you questions like it's, I mean, you're gonna feel like you're under pressure, but the whole point is you're there to learn. You know, you're a student, you're paying to be there to learn. And someone's trying to teach you with sort of the Socratic method of you know, medical knowledge.