Episode 126: Umbilical Hernias | Hernia Talk Live Q&A

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Speaker 1 (00:00:10):

Hi everyone, it’s Dr. Towfigh. Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I’m here with you every Tuesday. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. For those of you joining me on Facebook at Dr. Towfigh, thank you as a Facebook Live. Also, many of you’re here via Zoom, as you know at the end of this and with all my previous episodes, you can watch it and share it on my YouTube channel from my YouTube channel at hernia doc. And also thank you for those that follow me on Twitter and hernia Doc. We had a lot of Twitter activity this past week as I was at a conference, so thank you for those of you who follow me there. So I’m very excited because I have a great colleague of mine from Texas, Dr. Gabriel Arevalo. He is a hernia and gastrointestinal surgery specialist. He comes from out of Houston, Texas. You can follow him on Facebook at Dr. Arevalo and please say thank you and hello to Gabriel. Hi.

Speaker 2 (00:01:17):

Hello everyone. Thank you for hosting me. Very excited of talking about this very, very common topic.

Speaker 1 (00:01:27):

Yes, very common

Speaker 2 (00:01:28):

Problem to have.

Speaker 1 (00:01:29):

You’re very passionate about it because even before we started live, we’re still talking about hernias and so on. So many people get hernias and I always joke because when I go on Instagram, the only thing I look for are people’s hernias, like their belly button hernias. Especially nowadays, everyone’s wearing like midriff bearing outfits on Instagram. So it’s kind of become a hobby mine. And so now people actually DM me and text me pictures of belly button hernias they see on a movie or on something, social media post.

Speaker 2 (00:02:05):

You notice that the one on Shakira?

Speaker 1 (00:02:07):

Yes, yes. Super Bowl. Yeah. Yes. So she has a diastasis with a hernia, which is probably why it looked more. Yeah, because she’s had what, I think two kids, two or three kids now. I don’t know. I

Speaker 2 (00:02:21):

Think it’s two kids.

Speaker 1 (00:02:22):

Yes. More than at least two kids. It seems like the diastasis kicks in after the, not so much for the first pregnancy, but definitely two or more pregnancies and you start getting,

Speaker 2 (00:02:33):

There’s muscle separation there.

Speaker 1 (00:02:35):

Yeah. So maybe tell our audience a little bit about your practice. You’re in Houston, you do general surgery, you’re mostly GI and hernia surgery. Robotic surgery. Laparoscopic surgery. You have extra training in that. So maybe tell everyone.

Speaker 2 (00:02:54):

So my practice is located in Houston, Texas and here we have a hernia center as well as part of Houston Methodist. Yeah. What I practice, I do mostly all my surgeries through time, incisions, either robotic or laparoscopic. That is my two goal technique. Cause I can offer them something that not many surgeons are able to offer here. Yes. Is that faster recovery, that less pain. And my passion is hernias. That’s the most common. I will say if I have 10 surgeries on a week, it will be hernias, one will be a gallbladder and another one will be a little oh long that I need to do. That’s great. That’s great.

Speaker 1 (00:03:41):

Did you know you’d like hernia surgery from when you were in training?

Speaker 2 (00:03:44):

No, everything started by my last mentor. I went to this final training, six months of hernia and six months of gastrointestinal surgery. The acid reflux problems, belly pain, colonoscopies, endoscopies, but everything start to funnel down to hernias and I start to enjoy them. And when I got to practice, I realized that a lot of people suffered from them. If yes for you, for all you out there, about 175,000 umbilical hernias are repairing the United States

Speaker 1 (00:04:18):

At least. So

Speaker 2 (00:04:20):

It’s impossible to l a single surgeon to do all that work. So there is a lot of umbilical hernias out there, a lot of hernias and many ways and many cool ways to repair them. And that’s where my imagination kicks in all the techniques that we have learned. And it’s fantastic for the patients to offer them that.

Speaker 1 (00:04:41):

I always say to my residents when I’m operating that my favorite simple procedure is just a cute little small umbilical hernia. When you go from outtie to an innie, I just think that’s the best feeling.

Speaker 2 (00:04:56):

I’m going to give you an innie.

Speaker 1 (00:04:57):

Yeah. Yeah. And it’s such a nice cosmetic outcome. I’m not sure I’m, I’m saving many lives by fixing the small ones, but it definitely looks better.

Speaker 2 (00:05:08):

It makes you feel good. It’s time. It’s relaxing.

Speaker 1 (00:05:11):

It is. It is. And so in your practice, how much of your operations are open and how many are laparoscopic versus robotic?

Speaker 2 (00:05:21):

So the open ones are these tiny ones that I write. If I do an I in my office, I have the opportunity to do ultrasound. So we do this diagnostic test in my office and I’m able to measure it. If it’s less than two centimeters, a thin patient, we do them open. Then the vast minority are through timing, through robotic surgery. It is the big, big, big ones. The ones that we do open technique. Yeah. Cause it allows for better exposure I believe in or handling of tissues probably. Or they cannot tolerate for some reason the robot.

Speaker 1 (00:06:02):

And for simple umbilical hernias, not the big ones, not the complex ones. But for simple ones, do you do those laparoscopically or robotically? Yeah.

Speaker 2 (00:06:13):

So again, when a patient comes to my office, it’s very important for you for the audience to know, hey, what’s the size of my hernia? What is the size of it or what does it have in, what is that hernia holding? Is it holding in testing, is holding fat or is just a hernia sac? So depending to that, I do my decision. If it’s a tiny one, I do it open, especially the patient is slim. But if it’s a little bit bigger than two centimeters and a little bit heavy patient, I like to offer them robotic.

Speaker 1 (00:06:48):

I use

Speaker 2 (00:06:48):

The same day. Both of them, they go home the same day.

Speaker 1 (00:06:51):

Yeah. I also use one and a half for high risk patients and two centimeters for low risk patients is kind of my cutoff where you have to do more than just a simple umbilical hernia repair. So you use ultrasound in your office to just measure the defect? That’s a good idea. Yes, it’s,

Speaker 2 (00:07:10):

It’s pretty simple to do it. They don’t have to go out of the office to get the ultrasound. We do it, we do it right away. I just warned them a little cold jelly is coming cause of the ultrasound and that’s it.

Speaker 1 (00:07:23):

Yeah, because what you feel outside may not represent how big the hole is as surgeons we’re just interested in the hole, not so much. In fact, today I saw a patient, she was told she has a four and a half, almost five centimeter hernia and the radiologist was measuring how much fat was out. Not the actual hole. The hole itself was one centimeter. So that changed the whole plan. Completely different for one centimeter hole than a four or five centimeter hole.

Speaker 2 (00:07:56):

They tend to measure the sack is what we call it, the sack that bulges out,

Speaker 1 (00:08:02):

Which is totally unnecessary, right?

Speaker 2 (00:08:04):

Yes. It’s not necessary. You don’t need that. You need to know the size of the hole.

Speaker 1 (00:08:09):

Yeah, I agree. So we have several questions that have been submitted in online and then a handful that are coming in. So I’ll just moderate that for you. One question is, how commonly do you see umbilical hernias as compared to inguinal and incisional hernias?

Speaker 2 (00:08:28):

So hernias tend to be more common in my practice. And then I follow with the umbilical hernias. Umbilical hernias are definitely more common than incisional.

Speaker 1 (00:08:39):

Yes, correct. Can you explain why an umbilical hernia is different than an incisional hernia?

Speaker 2 (00:08:45):

So incision, let’s say you have your gallbladder removed and they have to remove that gallbladder out of your body. So they do it by creating an incision. Then they remove the gallbladder, they say they remove your appendix, the same thing. So whenever there is a failure, that hole that the hole that they created to remove the organ, when there is a failure of that hole too close and you leave it there, an opening creates there. That’s an incisional hernia because you have the hernia because they did an incision on you. Yeah. Umbilical hernia is coming from a virgin belly. They have never caught you there. Nobody has ever done an incision and it’s a hole that comes out at the level of your belly button.

Speaker 1 (00:09:33):

And you treat those differently.

Speaker 2 (00:09:36):

Not really an incisional hernia. Actually yes I do. Sorry. Yes, I do an incisional hernia. Most of the time I would like to put a prostatic on it to prevent a recurrence because it’s already a damaged tissue. They cut through that tissue for whatever reason that tissue failed to came together. So those patients, I will say most of the time I like to put a reinforcement to prevent a recurrence and hernia. Not all the time in my practice, eh, needs the need of a Mesh.

Speaker 1 (00:10:10):

Yeah. Okay. Let’s discuss that then. What’s your algorithm if you see someone with an umbilical hernia? An outtie, do you agree with me that pretty much an outtie is a hernia unless proven otherwise?

Speaker 2 (00:10:23):

Yeah, yeah, I agree. It’s a failure. All of us, we were connected to our mother’s eh womb from an umbilical cord. Yeah. That was coming from the mother into our belly button. Yeah. So when the baby’s born, the doctor cuts it, then that cord then falls apart and then immediately our layers get closed. And a failure of that closure. That’s the, that’s when you develop the outtie.

Speaker 1 (00:10:56):

Yeah, exactly. And then here’s another question which is, oops, wrong question, which is specifically what is the algorithm for someone who says, I was told I have a hernia, I have an outtie, but really it’s not bothering me what we call asymptomatic umbilical hernias.

Speaker 2 (00:11:20):

So it depends. There is a group of physicians out there that state that if it’s not bothering you, the umbilical hernia, if it’s you haven’t out, it’s not bothering, you had it for a long time, leave it alone. We call it watch and wait. But the key is this, what are you waiting? So that’s what I tell my patient. What are you waiting for it to get incarcerated or what are you waiting for it to get? For you to get pain?

Speaker 1 (00:11:51):


Speaker 2 (00:11:52):

Yeah. So I give them that option. There’s ones that are willing to wait, it’s not bothering me, then it’s fine. But some others, I tell them right now, you are young, you are strong, you are healthy. Let’s say 10 years down the road you’re going to be older. And unfortunately when we get older we get sicker. We don’t tolerate surgeries the same way as you were old when you’re young. So I tell them, if you want to repair it, I’ll say this is the time.

Speaker 1 (00:12:22):

And what if they say, you know what, I don’t want to have surgery now is that considered safe? Yeah,

Speaker 2 (00:12:30):

It’s safe. Again, if it’s not bothering you. Yeah, it’s not bothering. You had it for a long time. It’s an outtie. Yeah. It’s not bothering you don’t want it. I will say you can leave it a little bit.

Speaker 1 (00:12:41):

And which are the dangerous umbilical hernias? Do you have a formula as to which one is more likely to strangulate?

Speaker 2 (00:12:48):

I will say that if it’s more than a centimeter 1.5, that’s enough for an inner organ to get in

Speaker 1 (00:12:58):

The intestine. Yeah,

Speaker 2 (00:13:00):

Exactly. Or if all of us, we have a little bit a layer of fat protecting the inside of our tummy so that layer of fat can get in there and gets choke and that hurts. I see. I have seen patients bend from the pain. So that’s strangulation too.

Speaker 1 (00:13:17):

And I think that, I mean most umbilical, the majority of them are small and they have fat. That’s the first organ that goes in there. And often if the fat’s stuck in there, there’s no space for intestine to get in. So I’m okay if for those people are saying, I have no problems, can I just live my life? Sure, go ahead. But then if they have bowel in there for sure, that’s something that I would recommend. There was a great paper that said if your neck to sac ratio or sac to neck ratio is more than three to one. So the amount of content is three times more than the width of the defect, that’s a higher rate of strangulation. But I see that all the time and I’m not so sure if that’s a good formula

Speaker 2 (00:14:10):

That replicates to real life. And definitely if it has intestine in there, yes, get it repair and for the audience you can easily get to know during the physical exam or with the ultrasound in the office.

Speaker 1 (00:14:25):


Speaker 2 (00:14:26):

Very easy.

Speaker 1 (00:14:29):

Yeah. The next question has to do also with your management. What do you advise your patients when they ask them ask you how fast is it going to grow? Is it going to get really big by next year or is it going to take 10 years?

Speaker 2 (00:14:44):

So there is no rule in time, but there is a rule. If you start to gain weight, your belly muscles are going to en is going are they’re going to widen up and that’s going to make the whole bigger. Or if you have tend to develop constipation, you have problems, voiding peeing, training during urination, all those things, they’re going to make your whole to enlarge. But if you live a comfortable life, you don’t have any of those problems, you are slim. It’s pretty hard to tell you, hey, it’s going to grow up a centimeter in the next year. I don’t think, and I haven’t read anything related to that. How about you?

Speaker 1 (00:15:32):

Yeah, I I’d say it’s totally unpredictable. Most people, those small hernias and if they’re what I call low risk, so they’re fit, they’re not coughing, they don’t have constipation, they don’t use smoke cigarettes in California with have a lot of marijuana smokers. They’re, they cough a lot with the marijuana. So if you don’t have all those risk factors, you’re not obese, then probably that small belly hernia will stay forever. Some of these people that I watch on Instagram, they’ve had it for years and that damn hernia is the same size, but then they get pregnant, some of ’em. And I see that hernias now bigger. So you want to talk about pregnancy and hernias? I think that’s a good, yes. Relevant topic.

Speaker 2 (00:16:20):

So I’ll give you guys an example. If you have a balloon, a deflated balloon with no air, the wall is very, very thick. You start to inflate that balloon, the wall of the balloon is going to turn very thin. Same thing happens in pregnancy. Your muscles are thick, but once you get pregnant, start growing that belly, the muscles are going to become very thin. That’s a

Speaker 1 (00:16:44):

Good one.

Speaker 2 (00:16:44):

And that belly button is going to get wider. It’s going to get wider. Okay. It’s fine. You can go through your pregnancy with that. The problem is if it gets strangulated, strangulated means that it went in and start to choke the tested. That’s an emergency or a layer that fat that we all have inside. You can choke it. The best time to repair it is after the sec is in the second to third trimester. I will say the second trimester is the best time to repair it, but believe me, you don’t want to go through that cause so

Speaker 1 (00:17:24):

That, have you seen women that are pregnant that are strangulating?

Speaker 2 (00:17:29):

Yes, but only with the fat, not with the intestine. And that’s what I tell you that they hurt because there’s so much pressure inside your belly from the baby pushing the fluid, the baby moving, and you have that piece of fat that is, you’re not able to push it back in. So it’s get choke and choke and choke and they hurt a lot to the point they thrive.

Speaker 1 (00:17:54):

And cause most hernias, you would think as the uterus goes up, it kind of covers the hole. So that’s why you don’t see the intestines, right? Because intestines goes right. Oh

Speaker 2 (00:18:05):

Yeah. The displacement. Yes, you’re right. Yeah. It could be the displacement. It gets displaced and let’s say thank God, and let’s say everything goes fine and you deliver your baby. So when is the time for you to repair the hernia? We were recently discussing that it’s safe to say three months after the delivery or three months after you finish breastfeeding. Yeah.

Speaker 1 (00:18:33):


Speaker 1 (00:18:34):

That would be because of the hormonal changes of the abdominal wall. Yeah, you don’t want, I see women you probably see the same that they need a C-section and they have a belly button hernia. So it’s not uncommon for someone to be pregnant and have an outtie during pregnancy. You can see it through their clothing. It’s like a little pressure. And a lot of times that’s a really, really, really small belly button hernia. And once the baby’s gone and they’re back to their normal abdominal wall, that may not be a clinically relevant hernia. But others it may be bigger or it may have bothered them during surgery. I’m sorry, during pregnancy. So they say, oh, while I’m having my C-section, can you fix my hernia? What do you say to those people?

Speaker 2 (00:19:25):

I say, no,

Speaker 1 (00:19:25):

I know, me too. How do you explain that to them?

Speaker 2 (00:19:31):

So I tell ’em, Hey, you’re going to be the hormonal changes that we were talking.

Speaker 1 (00:19:37):


Speaker 2 (00:19:37):

So we have to, females have the surgeon and progesterone. Progesterone is the one that is up during the pregnancy and is causing the muscle to be laxity to be, yes. Very pliable. Yes. So you want the hormone down before you repair it.

Speaker 1 (00:19:55):

Yes. I see a lot of, a lot of people who they’re gynecologist or their obstetrician while I’m in there, I’ll go fix your hernia and it’s never good. I’ve never seen one where it worked.

Speaker 2 (00:20:09):

Thank goodness I haven’t seen one. Probably fixing one.

Speaker 1 (00:20:14):

I think the obstetrician’s trying to be nice, but it’s the wrong operation. It’s doing it in from the inside. Oh, they just sew. They don’t take down the actual pre peritoneal fat. So it’s the wrong operation to begin with. They probably use Vicryl, which is the wrong suture to begin with and it doesn’t work. So just leave her alone. See how you do take care of your baby once you’re done with breastfeeding, come and see you.

Speaker 2 (00:20:45):

Yeah, for the audience. Don’t choose that option. I’m fixing it.

Speaker 1 (00:20:51):

Yeah, I agree. At

Speaker 2 (00:20:52):

The same time. I agree.

Speaker 1 (00:20:55):

Okay. There’s a question about watchful waiting. It looks like you already answered that. Okay, so now let’s say the woman has delivered their baby and they A, let’s say it’s our second baby or third baby. So their belly’s already kind of stretched out and they have this belly but hernia. So what do you recommend for them?

Speaker 2 (00:21:22):

So they have the baby and you say you have the baby and the belly. The hernia is asymptomatic or symptomatic.

Speaker 1 (00:21:29):

Let’s make it easier. It bothers them.

Speaker 2 (00:21:31):

Okay. So if it’s bothering you and you already had the baby, the time is wait three months after you have stopped breastfeeding. And it’s because again, to going back, the hormone will go down after you stop breastfeeding and also your belly is going, is returning to normal. Yes. You may get, your surgeon may get the wrong perception. Oh, like you say, oh, it’s wider than I thought. Yes. Or it’s too the tissues too. It’s too polite apply because you’re doing it too early. If you wait a little longer, the tissues going to be stronger and it will have the more natural shape.

Speaker 1 (00:22:14):


Speaker 2 (00:22:15):

It won’t be confusing the judgment of your surgeon

Speaker 1 (00:22:18):

And it will hold the suture better.

Speaker 2 (00:22:20):

Yes, absolutely. The stronger tissue. So

Speaker 1 (00:22:23):

I made a comment about Vicryl sutures. So one of the audience members said, why is Vicryl the wrong suture for an umbilical hernia repair?

Speaker 2 (00:22:31):

Oh, because it’s going to dissolve. It’s going to absorb. It’s going to fade away. So you want something that could stay that’s for one Vicryl also, if you put it under the microscope is made of multiple threats. So those threats can get a, if a contamination happens. Cause sometimes they happen like

Speaker 1 (00:22:53):

C-section during a C-section. Yeah,

Speaker 2 (00:22:55):

Especially during C-section, some bacteria can get into that thread. You want a suture that is permanent and this a suture that is, we call it a mono suture, a single suture with no braiding. So that way you’re making it harder on the bacteria. Yeah.

Speaker 1 (00:23:18):

Vicryl suture or dexon, depending on the company, it technically loses its strength in about three weeks as it starts absorbing. So we usually don’t use that as a definitive hernia repair. We can use it for other things like skin and soft tissue or you don’t need that tensile strength. But we don’t usually use it for that. Here’s a question I get asked a lot. Let me show you the question. It says, I had laparoscopic surgery and ever since then I’ve had a diastasis where the abdominal muscles separate. Could the insufflation from laparoscopy cause my diastasis? Do you hear that?

Speaker 2 (00:23:57):

No. Actually first time. First time.

Speaker 1 (00:23:59):

Maybe it’s just my patients.

Speaker 2 (00:24:02):

Can you for patients? I don’t think so because the CO2 during the surgery absorbs is not done for prolong time. I don’t know how long it will take to remove the fibroids, but an hour or two, not that much. But what I’m worried during those ca No, this is fibroids, endometriosis, yeah. Then you can create seeding like Yes. Little microscopic I

Speaker 1 (00:24:37):

Think. So from endometriosis, conceded from lap, I

Speaker 2 (00:24:40):

Had a patient, I had a patient once that I fixed a her I fixed, she had a hernia repair in the past with Mesh and I went in between the hernia and the Mesh. She had endometriosis.

Speaker 1 (00:24:55):

Wow. From

Speaker 2 (00:24:56):

The previous surgery? Yes.

Speaker 1 (00:24:58):

No kidding. Between the hernia and the Mesh. Yeah. I’ve never seen that. And I see a lot of endometriosis. I work with a lot of these gynecologists who just specialize in it and I help them for any GI involvement of endometriosis. Plus many of them have chronic pelvic pain and sometimes it’s a hernia and not the endometriosis that’s causing the pelvic pain. The pain. Wow. So abdominal wall between the hernia and Mesh, that’s a difficult one. How did you figure that one out?

Speaker 2 (00:25:30):

Because was the patient had a hernia recurrence, so the Mesh had already, it was folded. It was folded on my side. So when I was planting and removing the Mesh, yeah, I’m like, what is this chocolate appearance? Wow. And I thought that it was the, cause we put a little bit of oil in the instruments of the robot. So I kept looking like, Hey guys, don’t put too much, look what you’re doing. And then I realized I will keep seeing more and more and I’m going to send it to the pathologist and boom.

Speaker 1 (00:26:05):

And then did their pain go away? Was that a reason? Yeah,

Speaker 2 (00:26:08):

Pain. Very happy. Very happy. Happy. Yeah.

Speaker 1 (00:26:12):

That’s pretty cool. I mean I good that you helped the patient too. Very interesting.

Speaker 2 (00:26:18):

Very lucky. Very lucky we found it.

Speaker 1 (00:26:21):

But a lot of patients that have told me, oh, I didn’t have this hernia or I didn’t have this abdominal diastasis until I had my laparoscopic surgery for something else. What do you think

Speaker 1 (00:26:32):

Don’t from that? I think they just noticed it for whatever reason. Because the pressure that we insufflate is maximum 15 millimeters of mercury and that can’t be, I mean a cough is much more pressure than that. Getting out of bed probably causes just that much pressure. So it can’t be from the insufflation, but every once in a while I wonder if, for example, how patients when they wake up from surgery, some of them wake up kind of violently and they do a lot of bucking before the tube is taken out. I wonder if that pressure

Speaker 2 (00:27:12):

Probably a hernia, maybe not to separate the muscles.

Speaker 1 (00:27:16):

Yeah, I agree.

Speaker 2 (00:27:17):

Spread them apart.

Speaker 1 (00:27:19):

I agree. Yeah.

Speaker 2 (00:27:21):

Maybe they just notice it more when after their surgery.

Speaker 1 (00:27:25):

Yeah. The next question is if you have an umbilical hernia, what are the symptoms that require going to the hospital?

Speaker 2 (00:27:33):

I will say if it hurts you at the belly, bottom level hurts you a lot and you see that the skin in the area has turned red. Oh yeah. And they’re warm to the touch in the area and you are feeling nausea and you haven’t gone to the bathroom to do number two, then you should go.

Speaker 1 (00:27:56):

Yeah. So yeah, I would say more than four to six hours of constant pain. Definitely that’s a sign of an emergency. Any redness or super, super painful, a belly button I would see I go to the emergency room and not wait because what are the consequences if they wait, do you want to explain?

Speaker 2 (00:28:17):

So you wait, if you wait, two things can be there. One could be the bowel, and if the bowel is choking there and it’s hurting you more than six hours, that means that more than six hours, the hernia has been choking your intestine. So most likely will die. And if it dies, then that’s a whole different type of surgery that you will need. You will need, likely they will have to open you. It requires a skilled surgeon to do it through time, through laparoscopy to get in and remove that dead segment of intestine reconnected and fix your hernia at the same time.

Speaker 1 (00:28:59):

Do you do a lot of emergencies and on-call work?

Speaker 2 (00:29:02):

I still take a ER call. I still do and I enjoy it. Yeah, I enjoy it. Because

Speaker 1 (00:29:09):

You’re young.

Speaker 2 (00:29:11):

I still have the energy, so I like it because you can actually, you help that patient in the moment. They’re desperate for the help. Yeah. And still I get that it feels, makes you feel very, very good.

Speaker 1 (00:29:30):

Yeah. My first job was that, my first job was, I was part of the laparoscopic surgery group, but we also took call for all everything that we called it non-trauma surgery. So there was a trauma team and there was a non-trauma. So if you came in and because you were stabbed, it went to trauma. Everyone else came to us. Dead bowel, bowel obstructions, necrotizing fasciitis, gallbladders, appendix. I liked it because I called it my box of chocolates, you know, never knew what would come in that day. Took care of it and it was really great. A way to just hone your skills and be a great surgeon.

Speaker 2 (00:30:13):

Yeah. You called the next morning and you’re like, how do you feel? I They tell, I feel great. Thank you. Yeah, thank you. I feel better. They’re eating.

Speaker 1 (00:30:19):

Yeah. Yeah. I mean I love hernias, but I just don’t have the energy to do that much call. I used to do so much in-house call, but it was very, very fun and satisfying because you did everything. Whatever came to the door, you handled it was really great.

Speaker 2 (00:30:38):

Oh no. They gave me the option to stay in the hospital and say, Hey, stay in the hospital 24 hours. I’m like, no, if I take the call, I’m taking it from home, from my home.

Speaker 1 (00:30:49):

Oh yeah. I was not given that option.

Speaker 2 (00:30:51):

No. I’m like, I want to sleep in my own bed.

Speaker 1 (00:30:55):

Yeah, it was, we operated between 10:00 PM and 4:00 AM that, that was like our, it was at the county, LA county and it was a very rigorous and fun at the same time. Yeah.

Speaker 2 (00:31:09):

I get a lot of patient flow. a lot of people consulting. Yes. The county hospital. Wow.

Speaker 1 (00:31:15):

Yeah, it was great. Very grateful. Patients. Wide variety. I even had a patient with the plague. Can you believe that?

Speaker 2 (00:31:23):


Speaker 1 (00:31:23):

Plague. The plague? Yeah. Yeah. We had one, if you read LA Times, Los Angeles Times, they report that there was a plague in the united in LA That was my patient. Yeah. Pretty crazy. Did you notice

Speaker 2 (00:31:37):

It? You saw

Speaker 1 (00:31:38):

It? I had no idea. I had no idea. I was on call and I got a phone call from the Los Angeles County, like Department of Health or something and they said, are you Dr. Towfigh? I said, yes. They said, do you have a such and such patient? Yes. She said, we’re calling because her cultures grew yersinia pestis.

Speaker 2 (00:32:01):


Speaker 1 (00:32:02):

And I’m like, what’s yersinia pestis? I said, that name sounds very familiar, but what is yersinia pestis, and she said, that would be the plague. Yeah. Yeah.

Speaker 2 (00:32:19):

Shower, wash your hands, wash your clothes.

Speaker 1 (00:32:22):

It’s a great story. I’ll share it with you in details later. But it was a poor family that couldn’t afford meat and protein. And so the husband would go to the local park and kill rabbits that were, there’s like a rabbit area that was just, and then he would serve rabbit meat and those rabbits had yersinia pestis. So he got his wife sick. And Levaquin is the treatment, if you ever have anyone with the plague, it’s Levaquin. Yeah. We gave her Levaquin just because we didn’t know why she was so septic, but it worked. We saved her life, but we didn’t know until

Speaker 2 (00:33:13):

Two days later, rabbits in Houston,

Speaker 1 (00:33:16):

Rabbits, squirrels and what do you call it, bats rabbit squirrels and bats get it.

Speaker 2 (00:33:25):

It’s squirrels. We have a lot.

Speaker 1 (00:33:27):

Yeah, so do we. And of course like rats, but they lived in a rat infested area of town and they tested the rats and there was no rats that had it. But then they figured out he was killing rabbits to feed his family.

Speaker 2 (00:33:46):

Interesting guy, huh?

Speaker 1 (00:33:47):

Yeah. Interesting story. In fact, when the way they figured out is this is not related to hernias in any way, but it’s a good story where they kept going to his home to try and figure out where this yersinia pestis was. And very lovely family, very poor. They offered him or her some pate when the health department came to visit. And she’s like, no, thank you. What is that? And he said, it’s rabbit meat. And they’re like, rabbit meat, huh? Where did you get this rabbit meat? Then the man got really nervous and he said the local grocery store. And they knew that you can’t buy rabbit meat at the local grocery store. So that’s when the story came and then he admitted that it was his little delicacy he would make pate. So it wasn’t cooked and it was from that rabbit meat. Yeah. They tested it with positive. Yeah. Interesting story. Yeah, he felt really bad. He almost killed his wife, but it was obviously not intentional. He was trying to help his family. Yeah.

Speaker 2 (00:35:05):

Give some protein

Speaker 1 (00:35:06):

Came up protein. I know. Okay, well back to hernias. For umbilical hernias, what are the predisposing factors?

Speaker 2 (00:35:16):

So any, I’ll say anything that increases the pressure inside your tummy.

Speaker 1 (00:35:23):

Good. Yeah, agreed.

Speaker 2 (00:35:25):

We’ll give you a belly button. Hernia. Anything that increases like pregnancy, increases your pressure coughing. Straining for bowel movements. Yes. Training for urination because

Speaker 1 (00:35:40):

Of enlarged prostate. Yeah,

Speaker 2 (00:35:42):

Enlarged prostate. And interestingly, I found this very interesting. It’s common that patients think, oh, when I’m in the gym lifting, right? Yeah. Actually that one does doesn’t cost that much pressure inside your tummy. Right? You’re because you’re using your other muscles.

Speaker 1 (00:36:01):

Yeah. In fact, how many body builders, you know that need belly button hernia repairs? Almost never. Yeah. Or athletes. Yeah, they don’t have it. Yes. Although during the Olympics, I did notice some belly button hernias, but they were really small.

Speaker 2 (00:36:15):

Little outties.

Speaker 1 (00:36:16):

Little outties. Yeah. Couple of track stars had it go on my Instagram, I posted the track stars. Okay, great question. Coming in live, can you also talk about diastasis recti? When are they dangerous and when should they be repaired? What about the combination of a belly button, hernia and diastasis recti? How are they handled when occurring together? That’s a great question.

Speaker 2 (00:36:42):

So as hernia surgeons, as especially laparoscopic surgeons, yeah. We have the advantage that we can fix a belly button and the rectos diastasis the muscle separation at once, and we can achieve that repair through the same tiny incisions as opposed to plastic surgeons that they have to do a huge cut at the level of your bikini line and do a huge flat lift up your skin and fatty tissue to fix your belly button and fix your muscle separation all the way up to your breast bone.

Speaker 1 (00:37:20):

That’s a tummy tuck?

Speaker 2 (00:37:22):

Yes. Yeah. But we’re able to do it through tiny incision. We can definitely fix that. And I will say dangerous for diastasis when it becomes too wide. When it becomes too wide, then your abdominal muscles and your back muscles are not working properly.

Speaker 1 (00:37:41):

Yeah. Core. Yeah. You

Speaker 2 (00:37:42):

Don’t have what we call it the core, the core muscles. So all of us, we have an abdominal wall. This wall is supposed to be holding things in place and it’s not functional, it’s not proper, it’s not doing its proper job when the muscles are separated and especially if you don’t exercise your back muscles. So where is the core getting their strength? I read a couple of papers that even patients that have problems like C O P D, difficulty breathing and diastasis, you’re fixing their diastasis and they tend to breathe better. Oh,

Speaker 1 (00:38:21):

Cool. The diaphragm is part of your core.

Speaker 2 (00:38:24):

Yeah. You don’t have those, your accessory muscles for breathing.

Speaker 1 (00:38:30):

So what operation do you offer them?

Speaker 2 (00:38:34):

So I do, if they don’t have a belly button, if they do not have an umbilical hernia, yeah, I do their incisions at the level of the bikini, at the bikini line and I fix their muscle separation. If they have a belly button hernia, I do two incisions on their upper belly and I do those two incisions in the upper belly, tiny ones. And I create a space around the muscle separation and then I move again to the bikini line and I fix it from below, from the bottoms up from the belly bottom up. So they end up with two more skin incisions. If there is no hernia, they get three incisions at the beginning line. If they have a hernia, I fix them with five tiny incisions, two in the upper belly to create the space and then I move down in between the

Speaker 1 (00:39:38):

Legs. Okay. Let me ask you this. Okay, so we’re talking about laparoscopic or robotic plication of the diastasis with or without belly button hernia repair. So what we’re talking about is people who have umbilical hernias, they have a variety of options for repair. But if the umbilical hernia is within the diastasis, so it’s everything we’re talking about is the middle of the abdomen, but if the hole is floating in a thinned out part of the abdominal wall from a diastasis, it could be in men or women, then closing that hole has a higher failure rate because it’s very thinned. Exactly right. So yeah, you’re proposing don’t do that. Let’s fix the whole thinned out part. Exactly. And that will support the belly button, hernia repair or just Exactly. Okay, so you’re doing the, I

Speaker 2 (00:40:35):

Don’t think it’s right to just fix the, I don’t think it’s right just to fix the belly button. Yeah. And then you patch it with a Mesh. Yeah. Then you have created a very strong area there. But the other rest of your belly, the diastasis is a area of weakness. So yeah, the hernia can come back there. So

Speaker 1 (00:40:57):

The traditional repair is a tummy tuck. It’s very large, lower abdominal kind of incision and then clear all the fat and skin off of the muscle all the way to the chest wall. Find the narrow the widening, tighten the widening, and then reposition the belly button with and take out extra skin. That’s a typical tummy tuck. What you’re saying is you’re putting three trocars in the lower abdomen where it’s not visible and you’re doing the same procedure in terms of removing the skin and soft tissue, the fat off of the muscle, demonstrating the weakness, and then you’re closing it. So that’s like repa, lira, scola, all these term, Milos, all these different terms for it. Do you use Mesh for that?

Speaker 2 (00:41:51):

Not if I’m doing it over this, not if I’m in the adepose tissue and muscle. Yeah. If I’m do doing what those techniques as repa, I won’t. But if I do this for the audience, there’s many ways to do this. Yeah,

Speaker 1 (00:42:06):

There’s a lot of, there’s like five different terms for it. Milos, scola, repa, lira, it depends on which surgeon described,

Speaker 2 (00:42:15):

But for example, today, today I did a patient that she had a wider tummy. Alright. She’s not skinny, not thin. And so she has a wide tummy. So I did, instead of doing the transitions at the bikini, I did them on her side. And then the robot has less chances of colliding, it’s easier. And on that patient from the inside, I fix the belly button and I just go up all the way to the cyphoid process. All the way to the ribcage. Yeah. What we call it plication, bringing it together. Yeah. It’s like whenever you have an accordion,

Speaker 1 (00:42:58):

Good analogy. You’re very good with your I like that.

Speaker 2 (00:43:04):

And then you bring it together. And nowadays the in a group that you and I are, we call it the International Hernia Collaboration. Yes. They post a very nice way to do this stitches, so the patients don’t see the reach on the outside.

Speaker 1 (00:43:20):


Speaker 2 (00:43:21):

So I I’m doing that even more nowadays.

Speaker 1 (00:43:27):

And then you don’t reposition the belly button, you just take it off and then push it back, sew it back down. Yeah,

Speaker 2 (00:43:32):

Sew it back together. Yeah. Give the in again.

Speaker 1 (00:43:36):


Speaker 2 (00:43:38):

Do you reposition the belly button?

Speaker 1 (00:43:40):

Well, so here’s my story. So I started doing these robotically posterior plication, not anterior plication.

Speaker 2 (00:43:47):

Posterior placation. Huh?

Speaker 1 (00:43:49):

Posterior. So extra peritoneal posteriorly. So instead of sewing it like a plastic surgeon would do, I would do it from the inside and they did very well. However, I then looked at my data to see how the patients D did. First of all, you’re right, they get like this ridge, but that ridge lasts about three months and then it goes away. For most people, they don’t see the ridge. But pose, I was not using Mesh and I would do two layers of closure. And if there was a hernia, I would fix it as part of the hernia. But what I found was, especially if I did it in men, they have this kind of very rounded belly, they fell apart, a good proportion of them fell apart. The hernia didn’t though. So what I learned was if I’m doing it, doing the posterior placation to sew that muscle together in order to give a better hernia repair to kind of support the hernia repair, that worked very well. But if I did it purely for cosmetic purposes to give them a flatter belly, it wasn’t good because a good proportion of them tore apart.

Speaker 2 (00:45:00):

But you were not using Mesh.

Speaker 1 (00:45:02):

I was not using Mesh. Correct. So what I learned was if the goal is to give application and not just fix the hernia, I should be using Mesh, especially in these very rounded male abdomens. These were not obese men necessarily, it’s just they got that kind of rounded look. So I did more research on it. The anterior plication is just a better repair. It’s stronger. Plenty of data by the plastic surgeons showing that you can do a non Mesh anteriorly, even for really wide hernias. And they do very well. My issue with anterior, and I’d like to see what your opinion is. Unlike the plastic surgeons, we are not releasing all the skin in the fat. And so, and that’s still attached to the

Speaker 2 (00:46:01):


Speaker 1 (00:46:02):

That’s still attached to the muscle. And therefore my concern is that cosmetically, that skin and soft tissue is going to look ugly because it’s being pulled tighter. And so you get this extra skin in the middle. Tell me more about that.

Speaker 2 (00:46:20):

Exactly. Today. So I have clinic in this,

Speaker 1 (00:46:25):

Remember I’m in Beverly Hills, remember mine? Yeah. My concerns

Speaker 2 (00:46:30):

Mine is Galveston, not that fancy. So I had a lady today that exactly what you’re saying, and she told me, but what is this now? And it was the floppy skin. Yes. And I’m like, yeah, that’s eh, that’s fat. That’s fat that you have. And you can keep losing weight, burning the fat, but you will start, that floppy tissue will still be there. And unfortunately that’s one of the pitfalls I would say. Or the, yeah. But very,

Speaker 1 (00:47:13):

So I offer that for people that have a little bit more skin and fat because you can’t tell as much. But if they’re very thin, I still say tummy tuck is better or because they’re not going to be happy with the skin part of it.

Speaker 2 (00:47:33):

How about from the inside with Mesh on those skinny ones?

Speaker 1 (00:47:36):

Yes. So I offer that to them. Some of them don’t want Mesh, but yes, if they’re okay with Mesh, I could do posterior repair, add the Mesh, and that ridge will go away. It just kind of flattens out and not an issue. But I always tell them that. But the anterior repair is better repair, but some of ’em are not good candidates for tummy tuck because they have no extra skin. Here’s another question. Can a TEP repair, so this is a laparoscopic inguinal hernia repair that’s done extra peritoneally. Can a TEP repair for an inguinal hernia be safely done in a patient with a known umbilical hernia and diastasis? In other words, can the blind retro, it’s not blind by the way, but retro muscular dissection be safely done without enlarging the diastasis? Yeah,

Speaker 2 (00:48:29):


Speaker 1 (00:48:30):

Yeah, yeah. Not an issue at all. Yeah. Let’s see. Oh, here’s a question. We kind of answered it, but it’s

Speaker 2 (00:48:40):

A pre-medical question.

Speaker 1 (00:48:42):

Oh, I know. My viewers are so smart. They ask really good questions.

Speaker 2 (00:48:48):

They read a lot,

Speaker 1 (00:48:49):

Which umbilical hernia does not require Mesh to fix.

Speaker 2 (00:48:54):

I will say if you are thin patient and your hernia, in my opinion, less than two centimeters, yeah. I wouldn’t use Mesh.

Speaker 1 (00:49:06):

Yeah. So how about you? So here’s how I tell it. So the studies say one centimeter, but I think that’s just a bad study. In other words, scientifically speaking, if you compare Mesh or no Mesh for anything over one centimeter, the P-value, right? The significant value drops out at one centimeter. But the difference clinically is so different. It’s like barely anything between Mesh and no Mesh for zero one centimeter, one and a half centimeter, maybe even two centimeter hernias. So I do what you do. Exactly. So for low risk patients, I’m willing to do a tissue repair without Mesh up to two centimeters wide. For a higher risk patient, I get antsy after one and a half centimeters.

Speaker 2 (00:49:52):

Okay. And those ones you do Mesh and then you do those through laparoscopy or you will still do it open

Speaker 1 (00:50:04):

For Mesh? I would do laparoscopic, yeah. I don’t like to do open Mesh repairs for umbilicals. Yeah, there’s no good benefit to it. Yeah. Okay. Here’s another question. It says, what is your preferred technique for to fix umbilical hernias?

Speaker 2 (00:50:22):

So it depends on the size. So if the size, the same thing that we were just talking a small less than two centimeter thing. My preferred technique is to do an incision inside your belly bottle

Speaker 1 (00:50:36):


Speaker 2 (00:50:39):

In the outtie, I cut it and I typically mark the patient. I tell them, Hey, maybe half an inch is going to be outside your belly block.

Speaker 1 (00:50:49):


Speaker 2 (00:50:53):

But you can barely see the scar. So that is my preferred technique. Same as you. I love that procedure. I enjoy it so much. So

Speaker 1 (00:51:01):

Cute. Right.

Speaker 2 (00:51:02):

And then late, the other ones, I fix them robotically with three incisions on your side.

Speaker 1 (00:51:11):

Yeah. And I agree with you. Same laparoscopic or robotic. And I almost make it like a challenge because I always operate with residents and fellows. How perfectly cosmetic can we get? It’s like my little plastic surgeon in me comes out when I do belly button hernia. It’s like, how perfect can I make that belly button look? I’ll share with you a trick. So when you do the any part, don’t bring it straight down. Go maybe like five to seven millimeter south. Oh, okay. Yeah. Because if you go straight down and when they stand, the belly button hooks upwards. But if you go a little bit south, when they stand, the belly button goes exactly backwards. Because when they keep

Speaker 2 (00:52:01):

Going with the, the incision out of the belly button down,

Speaker 1 (00:52:06):

No, the incision’s fine. Your incision’s fine. But sometimes you have to take the stock of the belly bottom skin and sew it down on the fascia. So instead of sewing it straight down, I hear

Speaker 2 (00:52:19):

You. Yes.

Speaker 1 (00:52:21):

Sew it a little bit further towards the feet, like maybe five to seven millimeters. That way when they’re all healed and they’re standing and looking at you, the belly button stock is straight back. Otherwise it tends to tent up.

Speaker 2 (00:52:39):

Okay. Yeah, I’ll try it.

Speaker 1 (00:52:41):

My little trick. You heard it here first. Another question. How do you decide when to do open or laparoscopic for diastasis repair and how do you decide when to use Mesh?

Speaker 2 (00:52:57):

So for diastasis, I don’t do open for laparoscopy, eh, when I do a laparoscopic and then when to use Mesh. If I’m fixing it from inside out, from the inside posterior and posteriorly, I always use Mesh. And on the outside, when I’m fixing it from the outside, I don’t use Mesh because I’m worried that people are going to develop fluid there and that you put a drain. Yeah. Yeah. That fluid is not going to allow the Mesh to incorporate. Some mother say that it doesn’t matter that it stay, that it will in that the body will incorporate into the Mesh very easy. And I’m just a little bit more careful.

Speaker 1 (00:53:46):

Yeah. I would say my answer is for open, you have to have a lot of excess skin to be worth it to do an open abdominalplasty because that’s part of the tummy tuck. And anyone with a really wide diocese, so I would say four or five centimeters are great or wider, probably better to do it open by a plastic surgeon board certified plastic surgeon. The laparoscopic or robotic, it’s a better repair anteriorly than posteriorly. And therefore if I do it posteriorly, I have to use Mesh. However, it’s really hard for me to find the right person to do it anteriorly because of this issue with the skin. So it depends on how important the cosmetic outcome is for the patient and how thin they are, I think for me. So that’s great. I struggle with that. I haven’t come up with a perfect solution yet. I don’t know

Speaker 2 (00:54:45):

How you have opened up my eyes in regards to that floppy skin that develops at the end. That’s true.

Speaker 1 (00:54:54):

Yeah. Yeah. It’s because you’re not releasing the skin laterally and you’re not taking out any extra skin in the middle. So you’re bringing the me the muscle together and the muscle’s attached to the skin, especially laterally. So it’s seen people who’ve had it done and it just doesn’t look right. No amount of massage is going to make that skin move off of the muscle

Speaker 2 (00:55:18):

Matter how much collagen they buy and apply.

Speaker 1 (00:55:21):

Yeah, that’s not going to work. Yeah, it’s a problem. Or they do this skin burning. Have you seen that?

Speaker 2 (00:55:28):


Speaker 1 (00:55:29):


Speaker 2 (00:55:30):

Cold or laser? No,

Speaker 1 (00:55:32):

The, it’s called vaser lipo or there’s some other terms where they go behind the skin and they burn the dermis and it tightens the skin.

Speaker 2 (00:55:40):

Oh, wow.

Speaker 1 (00:55:41):

Yeah. They do a lot of weird things. I guess that may work, but I don’t know. Plastic surgeons have a lot of, a lot of tools.

Speaker 2 (00:55:51):

Any tricks.

Speaker 1 (00:55:52):

Here’s another smart question. I did not come up with any of these, by the way. If the belly button is such a weak spot, why do surgeons use it as a trocar port site for laparoscopic surgery?

Speaker 2 (00:56:06):

I would say that’s a very good question. Right? Yeah. And right. It’s a weak spot. Yes. I will believe that we use it. One, because we are in the middle of the belly

Speaker 1 (00:56:20):


Speaker 2 (00:56:21):

We can have a A panoramic view. We can go up, we can down left, right? Yeah. And the third is that we can hide that incision. Yeah. Inside your belly button.

Speaker 1 (00:56:32):

Yeah. I would say for bariatric surgery, many surgeons do not go through the belly button because the patient is already obese and therefore they have a higher risk of an incisional hernia from that trocar site. So they often go off midline. You did you get bariatric training too, as part of

Speaker 2 (00:56:51):

Your I did. Yeah, we did. We did bariatrics.

Speaker 1 (00:56:53):

Did you go off midline with your

Speaker 2 (00:56:56):

Al and even the removal of the stomach is done on the,

Speaker 1 (00:57:01):

Through the

Speaker 2 (00:57:02):

Rectus through the side of the Midland? Yes.

Speaker 1 (00:57:04):

Yeah. Yeah. Because it saves, it’s a better

Speaker 2 (00:57:08):


Speaker 1 (00:57:09):

Yeah. Yeah. So that all makes sense. Yeah. So

Speaker 2 (00:57:14):

That’s a good question.

Speaker 1 (00:57:16):

It’s a great question, right? Yeah. Okay. So Gabriel, what kind of practice do you have if someone wants to see you? I get a lot of patients from Texas. And you’re right, there are very few of you in Texas. They’re

Speaker 2 (00:57:34):

Like, yes.

Speaker 1 (00:57:35):

There’s like almost, there’s like you and maybe one other person that I can think of that does hernias

Speaker 2 (00:57:41):

For a, I know a guy in the me, sorry, MD Anderson. Yeah. And then in the medical center, which is, but you

Speaker 1 (00:57:48):

Can’t see him. That’s David Santos. He was one of our guests. You can’t see him unless you have cancer.

Speaker 2 (00:57:54):

It’s hard. Yes. Hard to get them. And in the medical center, the largest medical center in the world, most of the surgeons, not nothing bad, but they do open. Yeah. So how can you see me? I have, you can go to my webpage, gabrielarevalo.com, it’s my name gabrielarevalo.com and just hit the contact us. Send me a, your comment. Yeah. Your name and my medical assistant will reach out to you via email or via phone. If you call our office, most of the time we don’t answer. It is bad. The telephone system is not the best. But if you leave a voice message, we do listen to the voice message every single afternoon.

Speaker 1 (00:58:41):

And what if they’re outside of Texas?

Speaker 2 (00:58:43):

They can, for example, I saw a patient today from out of state, we do a telephone, phone, telephone visit. Yeah. It can be telemedicine, but for that one, they have to, they are Bill. But if it’s just a telephone phone, a quick phone call for him, for me to introduce to the patient or the patient to introduce to me vice versa, that is at no charge. We can Oh, you offer

Speaker 1 (00:59:07):

That, that’s

Speaker 2 (00:59:08):

Great. We can establish a relationship and if you like what you listen or have a quick some, cause sometimes imagine they’re going to travel from out of the state to see me and they will be like, Hey, I have, I don’t know, something different that they think is a hernia, but it’s truly not a hernia. Yeah. Then I save them that trip.

Speaker 1 (00:59:30):

Okay. So if they’re out of, because we can’t practice out of our own state. So if you have someone, let’s say in Chicago that wants to see you, you’re willing to speak with ’em on the phone to see if it’s an appropriate for them to fly in to see you and then they’ll fly in to see you. Yes. That’s very nice. Exactly.

Speaker 2 (00:59:46):

Exactly. Exactly. Of course, before this phone call, they have run their insurance. My medical assistant have run their insurance. Yeah.

Speaker 1 (00:59:57):

Okay. Well that’s very nice of you. Yes.

Speaker 2 (01:00:00):

Again, Gabriel a.com. Very easy to get a hold of them.

Speaker 1 (01:00:04):

And you’re also on Facebook, Dr. A. Yes.

Speaker 2 (01:00:06):

Facebook. Yeah. On Instagram. Same thing. Dr. Gabriel Arevalo.

Speaker 1 (01:00:11):

Yeah. You have good videos. I’ve watched her videos. Very good.

Speaker 2 (01:00:15):

Little bit of me and a little bit about hernias.

Speaker 1 (01:00:18):

Yes. Well, that’s it for us everyone. That’s the end of Hernia Talk Live, our weekly Q&A with excellent colleagues of mine that I share with you. Dr. Gabriel Arevalo did a great job of donating some of his time, talk about umbilical hernias. Thank you everyone for following me on Facebook at Dr. Towfigh, do go to my YouTube channel, subscribe every week. We’ll post the, that week’s session and you can watch it while you’re brushing your teeth or driving. You can find me at Hernia doc on YouTube. And again, Gabriel, thank you so much. I really appreciate. Thank you

Speaker 2 (01:00:56):

For limitation.

Speaker 1 (01:00:57):

Thank you. And hope you have a good night.

Speaker 2 (01:00:59):

Thank you. Thanks. Bye-Bye

Speaker 1 (01:01:00):

Everyone. Bye-bye.