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Speaker 1 (00:00:10):
Hi everyone. It’s Dr. Towfigh. We’re back on Hernia Talk Live here, trying to do almost every Tuesday as our live q and a. My name is Dr. Shirin Towfigh. You see me as your hernia and laparoscopic surgery specialist. Thanks everyone for joining us live on Facebook at Dr. Towfigh and some of your live on Zoom. And thank you everyone for also following me on hernia on Twitter and Instagram at hernia doc. Today we have a great, very exciting guest. Dr. Jenny Shao is a hernia specialist currently at University of Michigan. You can follow her at Jenny Shao MD on Twitter. And I’m super excited because we just finished a week in Montreal together talking about hernias and other things in very cold weather, and now we’re getting back to our normal lives. How are you, Jenny?
Speaker 2 (00:01:06):
I’m good. Thank you so much Dr. Towfigh, for inviting me to be on your podcast. This is really exciting. I’m looking forward to the great discussion and answering some questions.
Speaker 1 (00:01:16):
Thank you. So the reason why I thought of bringing you on is you are one of our kind of rising stars in hernia surgery, and I’m super excited that you’re joining my friends in Michigan because it’s just a great opportunity for everyone, both for them and for you. And maybe you could explain a little bit about how you got there. And that’s what I’d like to kind of talk about because I’m, I am personally very fascinated by these very great little hotspots around the US or the world. Some of them seem kind of random. Why is South Carolina a great place? And then we have nothing in Texas that makes no sense to me. So we’d like to kind of explain how it is that there are certain areas of excellence in the US for hernias especially you’ve trained and worked at many of them. And kind of start there because patients are always asking, where do I go? I don’t know have anyone local, but why is it that certain areas have a concentration of surgeons and other areas? So maybe first explain how you got to where you are now.
Speaker 2 (00:02:32):
Yeah, that’s a great question. I think I talk about this with my residents all the time because a lot of them have this question, well, how did you decide on hernia surgery? How did you know that this was a specialty for you? And so when I was a resident in my fourth year, I realized that I wanted to do minimally invasive surgery. And currently, a lot of the hernia fellowships are done through minimally invasive surgery fellowships. And one of my mentors and Dr. Parog Bhanot, who’s based out of Washington DC is pretty active in the hernia world. So he really highly recommended fellowship at Carolina’s Medical Center, which is headed by Dr. Todd Heniford and Dr. Vedra Augenstein. And they’re absolutely phenomenal and
Speaker 1 (00:03:17):
Yeah, yeah, prior guests on Hernia Talk.
Speaker 2 (00:03:19):
And so when I did my fellowship with them, I think they just taught me so much about what it means to be an excellent hernia surgeon. They’re just amazing specialists at the top of their field, and I think it’s really their patient-centered approach and multi-disciplinary approach that really I think helps patients get to where they need to be, especially for complex hernia cases. And so I think at the end of the day, the areas in which people or hernia specialists or surgeons or hernia specialists are people who really, really treat hernia as its own specialty and not just as a general surgery case, like, Hey, this is something I do as a part of my practice. I think for a lot of hernias, surgeons, you’ll hear us say that we’re abdominal wall specialists and that’s what we like to specialize in, and these are the patients that we like to see.
Speaker 2 (00:04:08):
And of course, if you do things that you love to do and you treat disease pathology that you genuinely really care about and are knowledgeable about, I think you tend to make advances in the field. And I think that’s why sometimes we get more of the complex referrals and the complex patients. So I’d say that most hernia specialists around the world, around the world in the United States, and some of these hotspots really probably have a passion for hernia in terms of academics, in terms of research. And all of us are looking to continually learn from each other and evolve our technique. And I think at the end of the day, it’s a very small group of people. Everyone tends to know each other, and all of us will share ideas and small family, and we continue to evolve our technique.
Speaker 1 (00:04:59):
So then after your fellowship, your first job was?
Speaker 2 (00:05:03):
Oh, so yeah, I took my first job in Philadelphia at the University of Pennsylvania. I worked with Dr. John Fisher who’s a plastic surgeon. He also does a lot of complex abdominal reconstruction as well as Steven Kovac. We were sort of at three different hospitals at Penn, but they’re also amazing and phenomenal. And so I think definitely you’re going to find these little hotspots around the country where they’re more, what I would call abdominal wall reconstruction programs where you really have sub-specialized surgeons who mostly take care and specialize in complex hernias.
Speaker 1 (00:05:39):
And we had Dr. Fisher on just, I think it was last year, one of the few plastic surgeons that are actually interested in abdominal wall reconstruction as our primary focus. That was really great. Great hour with him. And then you moved on.
Speaker 2 (00:05:56):
How long were you Philadelphia?
Speaker 2 (00:05:59):
So I was in Philadelphia for about two and a half years, and now recently I just took a job at the University of Michigan, so I’m coming to be the director of the comprehensive abdominal wall program. And I think that some of the things that we’re looking to build, and so actually one of my mentors, Dr. Dana Telem, who’s also here at the University of Michigan, she started this really great Michigan statewide Collaborative really looking at population data for hernia research. So that was one of the biggest draws in coming here. But also I think from a clinical side of things to be, I think in my opinion, a successful program, you really have to have some streamlined protocols, multi-disciplinary conferences and things that you can offer patients that can be a little bit more standardized in terms of your pre-operative operative and post-operative approach. I think having certain protocols in place and having people do things a certain way can improve the quality of care that you deliver. And so that’s one of the things that I’m really hoping to bring here to Michigan. And I think they’re already doing a great job of that. It’s just a matter of streamlining some of these protocols and making things more. And
Speaker 1 (00:07:09):
Yeah, I’m super excited that you’re there because I know they’ve been looking at conceptually thinking of having a hernia center. Michigan’s unique in that it’s a highly academic university based program and it’s always been clinically strong, but that the strength has always been its research and it’s very kind of pure that way. Whereas most other programs are just all about making money and have lost the knack of advancing care as a primary goal. So that’s really great. And there have been Dana Telem, your mentor and my very good friend, she’s done a great job of being the boss and hiring the right people for the right purposes. And now that you’re on board and there have been a couple other hires, you now have a team and you can start building and already have a following In Michigan, no, there’s really no one else in Michigan. I think before your group decided to build the hernia center, there really wasn’t anyone prominent where we would say, oh yeah, go to Michigan. And that’s changing now.
Speaker 2 (00:08:29):
And to be quite honest, I don’t know the landscape here in Michigan very well considering I just moved here. And I think there’s probably some good community surgeons here at Michigan that I don’t know very well academically. And I do think Dr. Tom has already built so many great things for the hernia program here. For instance, we have an optimization clinic where patients who are not ready for surgery can see our PAs to make sure they can meet all the right steps in terms of weight loss, smoking cessation, diabetes control before they get to surgery. And so I think we’re working on a couple of things where we can optimize outcomes for our patients before and after. And I think some of the things that I’m going to look to develop is incorporating more patient reported outcomes within our clinical practice. So having patients take surveys before they have their surgery, after they have their surgery, because at the end of the day, I think as a hernia surgeon, we always say We’re happy surgeons.
Speaker 2 (00:09:29):
We’re quality of life surgeons. The reason we operate is we want to make people better and we want to improve their quality of life. Most of this, I’d say like 80% is elective, right? Sometimes there’s emergencies, but most of the time the reason that we operate is because we feel like we can make a patient’s life better. And so in order to do that, I think you really have to set yourself up for success. And I think the program here at Michigan’s already done a great job of that. And I think as I’m coming in, I’m going to look to evolve some of the things including Botox and some robotic techniques and introduce that into the practice. So I think it’s going to be great. I’m really excited and I’m looking forward to really working with everybody here.
Speaker 1 (00:10:14):
Super exciting. So I always get questions, I’m in such and such state, who can I see? And I try and figure out of the people that I know in my web who be closest to them and try and hook up people because it’s hard to travel across state lines and you don’t have the family support. What if there’s a complication? It’s, it’s just much more complicated. And honestly, in the United States, we have enough advanced healthcare more than most other countries where you really shouldn’t have to travel that much. But I feel for hernia care, it’s very spotty. There are states and states and states that have zero well recognized hernia experts, and then you have all of a sudden boom, like a state which is not very populated, and yet they have really good several number of hernia specialists. So that’s always been very fascinating to me as I work in California.
Speaker 1 (00:11:11):
So there’s basically David and me in Los Angeles, and then that’s pretty much it. There are hernia surgeons that are very talented. Roxanne Lu is in northern California, but if you need someone who’s a revisional surgery, chronic pain, that kind of stuff, in the entire 40 million population of California, there’s only a handful of us. So that’s weird to me. And I’ve always wondered why that is. And what you’re telling me is it’s the leader, it’s Dana deciding that that’s going to be something that she’s going to put her attention and her resources against hire people like you. Why do you think certain institutions are interested in investing in a hernia center of sorts and others are not?
Speaker 2 (00:12:06):
Yeah, that’s a great question. And so I think I would say that the landscape of this is changing. So I think hernia surgery traditionally has always been known as not. It’s sort of part of general surgery. And so I think traditionally when we think about hernia surgery, we think of any general surgeon should just do be able to fix any sort of hernia. And I think a lot of special, a lot of specialties actually come in and do hernia surgery, but I think more and more we’re sort of starting to move away from that and it’s becoming its own subspecialized field. And because that’s happening, I think more and more you see of this investment in building a complex abdominal reconstruction center. And I think some of this comes from Dr. Heniford’s data where he’s shown that if you have a bad outcome or if you have a complication, these complications just sort of multiply away.
Speaker 2 (00:13:01):
It’s like a snowball. It just keeps going and going. And not only does the hernia come back, you could potentially have a risk for fistula, Mesh infection. And from an administrative standpoint, I think that that adds up to healthcare dollars. And so I think the more complications you have, the longer you to stay in the hospital, the more you need repeat surgery or even long-term antibiotics. All of that really eventually adds up. So I think ultimately at the end of the day, building a complex abdominal wall reconstruction center is somewhat of a cost savings because if you can streamline and optimize your care for complex patients, not only are you improving care for your patients, decreasing potential risk for complications, you’re also decreasing the amount of healthcare costs that’s going to be ultimately attributed to complex hernia care. True. So I think it’s really multifactorial, and I think more and more centers are recognizing that.
Speaker 2 (00:13:54):
Now, I always tell my residents who are going into M I S that I think hernia specialty is going to be a very hot field in the next 10 years because so many places now are recognizing the value of having a complex abdominal wall center. And it’s also because hernia hernias are so common, 20 to 30% of patients who have a major abdominal surgery with a large incision will end up with a hernia. And so there’s a true need for specialists. And I think ultimately, if it’s a small simple hernia, I think many general surgeons would do a great job at fixing it. But I think when we’re talking about these complex hernias, there’s just not that many of them out there. And most of them tend to go to these subspecialized centers. And so we’ve seen that migration of complex care to high volume centers, which I think also speaks to your point of having the hotspots. And I think it also shows good recognition by general surgeons who are in community because they’re sending away their complex cases to a tertiary care center or to somebody that they feel like would give the patient the best shot of success.
Speaker 1 (00:15:01):
True. So in the Michigan system, I don’t know if you are aware of their financial a business plan because for example, in my hospital, it’s mostly private hospital, whereas let’s say Cleveland Clinic, it’s employed. So in a private system, if someone refers a patient to me, let’s say that potentially means it’s not going to another surgeon in the area, and then that may affect their income. Whereas in Cleveland Clinic, they’ve already established all the gallbladders go here, all the hernias go there, all the colons go to this other group and so on. So who gets what? And they all kind of eat from the same pie, so to speak. So the way that the institution’s business plan is made up of also affects the ability to be able to build a hernia center. University of Michigan, I assume is a closed system. You’re all employed, you don’t have private doctors in your system, they’re if they’re private, they’re outside the University of Michigan system, is that correct?
Speaker 2 (00:16:12):
Yeah, we’re all employed by the University of Michigan, so it is a closed system in that sense. But I think the insurance carrier here, I think the biggest one is Blue Cross Blue Shield. So they’re really statewide. And I think that’s how we’re able to build such a robust research Collaborative as well is because a lot of this is also data that we’re going to be able to help pull from insurance carriers. But I do think that patients in Michigan are able to see other doctors within different healthcare systems. So we get referrals from hospitals in Detroit or even patients who are from northern Michigan, and they’ll come to University of Michigan and we’ll see everybody. So just because the surgeons are within, I guess more of a closed system so to speak, it doesn’t mean our patients are necessarily just all University of Michigan patients got, I think all of our patients come from across the state. True. And I think we also see patients from northern Indiana and northern Ohio as well. So I think it’s kind of a smattering depending on, on what’s convenient for the patient and where they elect to go.
Speaker 1 (00:17:22):
Those are other states that don’t really like Indiana, Iowa, they don’t really have a penetration of hernia specialists like certain other states do. We have a lot of questions from the listening and watching audience, so if you don’t mind, we’re going to jump into some of them because I like to keep my audience very happy.
Speaker 2 (00:17:44):
Yeah, that sounds great. Let’s do it.
Speaker 1 (00:17:45):
Yeah. Let’s talk really quickly about tram flaps. I assume you experienced plastic surgery outcomes while you were at UPenn working with Fisher. So can you comment a little bit about tram flap hernias? So hernias after a tram flap?
Speaker 2 (00:18:02):
Yeah, sometimes I find the tram flap hernia, so I think those can be a little bit challenging because it depends on the state of what the rectus muscle looks like after a trans flap. So I think for complex hernias like this, the most important thing is to get a CT scan to look at the muscles, to look at how large the hernia is. And sometimes with reconstructive surgery, you can also end up with certain denervation of muscles. And so sometimes I’ll see patients in the office where they’ll feel like they have a bulge or a laxity of their abdominal wall, but when I get the CT scan, what I see is maybe more thinning of the muscle from denervation and nerve injury. And as we cut into the abdominal wall, sometimes it’s inevitable. Obviously we try not to have that happen, and there’s certain reasons why we make incisions in certain locations, but sometimes, depending on the kind of surgery that was done previously, these denervation injuries can happen.
Speaker 2 (00:19:01):
And so I think it’s a a lot of sussing out whether or not it’s a nerve injury, what the muscle looks like, and what sort of coverage you can get. Because ultimately at the end of the day, when I’m explaining my thought process of what kind of operation we’re doing or why I’m offering this type of operation, I really like to show patients their own CT scans. And we talk about the fact that the hernia is a muscle defect, so essentially it’s a hole in the abdominal wall that’s allowing things to sort of come out into a space where it doesn’t belong. And in order to close the hole, we have to have good tissue and muscle coverage. And so I think so much of it is very personal and individualized depending on the kind of surgery patients would’ve had before. So I think definitely getting a CT scan and looking at the anatomy is really important.
Speaker 1 (00:19:50):
Yeah, very true. So specifically with the trans flap, they use the rectus muscle, the fashion, the skin of relying it to make a new breast. And there’s all you have is that kind of posterior layer, which in is not very strong. Some surgeons, they just close that up and you kind of get what they call a tummy tuck as a result of getting breast reconstruction with the tram flap in some ways because you kind of have to be able to close that posterior aspect without herniation. Some people even use Mesh in it, but if that falls apart or if that’s not done, then you get this very ugly and asymmetric abdominal wall, but it’s treatable. I think for a tram it’s usually treatable. It’s the diep flap that you’re referring to, which is the newer generation trim flop, which is supposed to have all the less complications. But the one major complication with the diep flap is the, that’s a very bad complication because it’s not a lot you can do with it. You have to be a little bit creative and ply Kate and use Mesh and so on, but it’s hard to make you look symmetric with a denervation injury.
Speaker 2 (00:21:01):
Yeah, I, and I think this speaks to the goal of why people are coming to see you for surgery, right? Yeah. So I think when I counsel my patients, they really try to understand what their goals are for an operation. Is this a functional goal that they have? Do they feel like the hernia is painful? Is it a cosmetic reason? And I think depending on what their ultimate goals are for why they want to have surgery, you would think about offering different things. And I think sometimes the most disappointing thing to say is that I don’t think a surgery would necessarily make this better, but sometimes that is the answer is yeah, it just kind of depends on what the hernia is and what the outcomes and goals are for the patient.
Speaker 1 (00:21:44):
So we have a patient who is very complicated. She’s a great follow of ours. So she has two issues. One is she has reacted to every single thing that’s been put in her body that’s been synthetic polyester, polypropylene sutures, meshes, they’ve all been, she has known chronic urticaria, so she’s already at risk. However, she’s also very hernia prone. So every time there the products are removed, she then gets a hernia that becomes symptomatic and she’s, I believe, diagnosed with a Ehlors type connective tissue disorder. So you kind of need it, the synthetic permanent Mesh because you’re a patient that’s constantly making hernias and your own tissue is not healthy enough to overcome that, but you react to every tissue. So she’s asking about Dr. Fisher over at UPenn, whether you think he would be someone that would take on such a situation, remove all of her Mesh, and then do a placation, like a tummy tuck of all of her hernias. Is that something that you’ve seen when you were there or?
Speaker 2 (00:22:59):
Yeah, I think Dr. Fisher’s a really talented surgeon, so he and I are at two different hospitals, but he and I actually operated together a couple of times. So I think technically he’s a good surgeon, and so I think it’s worth it to go see him to see what his recommendation would be in her specific case. Of course, I don’t know how large the hernia is and what kind of Mesh needs to be removed or what kind of meshes she’s had in the past. So one of the things that I really like is biologic Mesh. I think biologic Mesh works pretty well, and it’s not synthetic, it’s absorbable. And I think depending on how you use it, in what layer of the abdominal wall you use it in. Yeah, I think I’m a little biased in this sense, but I do think it works really well and it can incorporate really well with minimal side effects.
Speaker 2 (00:23:50):
So during my fellowship training, we did this a lot for patients who are immunocompromised or high risk for infection, even if they didn’t actually have active infections. And I think the outcomes have been really good. And in my own practice sometimes, most of the time I use it for patients that maybe have inflammatory bowel disease or high risk of potential intraabdominal infection or just patients who potentially are going to undergo chemotherapy for some sort of malignancy. So I’ve had pretty good success with that. And so I think it would be worth it to go see Dr. Fisher and get his opinion at the end of the day, if you feel like when you talk to him that it’s not necessarily what you’re looking for. He doesn’t have to be the one to do your surgery, but I don’t think getting another opinion would hurt. I think it’s always nice to see how different people approach, how, I guess different hernia surgeons approach different hernias, and maybe some of us will have different answers. True. And I think the most important thing is having trust in your surgeon and feeling like they’re actually listening to you to solve the problem that you need them to solve.
Speaker 1 (00:25:05):
Agreed. So true. Here’s another patient. He says, I had an inguinal hernia repair a few years back and I’ve been in horrible pain ever since. All the tests show nothing. Where do I go from here?
Speaker 2 (00:25:19):
Yeah, that’s a tough one. I think chronic groin pain is one of the hardest things that we deal with. And I’m sure Dr. Towfigh, you have plenty of patients as well who maybe are in the same boat. And so I, I’d say that, so I guess I don’t know if he had a minimally invasive operation, so laparoscopic or robotic versus open. So I think depending on which procedure he had previously, you could think about approaching it in different ways. And for work generally with these patients, what I do is when I have them come into the office, I do basically some dermato mapping where I sort of mark out the spots where there’s pain and I mark out areas that might be numb, and I mark out areas that are completely pain free and just sort of look at the nerve distribution along where this is potentially happening.
Speaker 2 (00:26:15):
And then other things I like to get are a CT scan to look, is there some sort of meshoma, meaning is the Mesh folded up? Is there some sort of inflammatory reaction that I’m not seeing? And then also potentially an MRI to roll out other causes of chronic groin pain. So that’s kind of usually my workup algorithm. And then I think the history is also really important. Did this growing pain start right away right after surgery? Because most of the time that’s a hundred percent some sort of nerve issue, especially if it’s immediately after surgery. Sometimes I think over time you can get a chronic inflammatory reaction in the groin that can cause pain as well. And so I think ultimately at the end of the day, there’s a lot of different answers depending on what the problem is. So if there’s a hernia recurrence, obviously fix the recurrence first.
Speaker 2 (00:27:11):
If it’s not a recurrence, then. And looking at the Mesh, if we think this is the Mesh problem, then does this Mesh need to come out? So I definitely would think about going to see a growing pain specialist. Yeah, yeah, for sure. There are some in this country. Dr. David Chen is really great. I think Dr. Brian Jacob in New York City has a really great reputation, and I think Dr. Krpata in Cleveland Clinic tends to see a lot of groin pain as well. And so it might be worth it to get a consultation. And I think Dr. Towfigh, you see groin pain as well. Do you?
Speaker 1 (00:27:45):
A lot. Yeah, I love it actually. I think I like the problem solving part of it a lot. But I think what you hit on the nail, the nail on the head was the story. So when people say, oh, all the workup was negative, that to me means nothing. What’s the story? When did it start? Like you said, timing is a very important because that narrows it down to different reasons. And then exactly the quality, the quantity, what makes the better, what makes it worse, or can you not do that alone? Once I hear this story, I know pretty clearly what I think is going on, and then that’s when I do procedures or tests, imaging, injections, et cetera, to help narrow it down or prove my theory. But the story is paramount. So just the fact that all studies were negative doesn’t mean anything because blood tests will be negative, imaging can be negative, and that’s really kind of how it is.
Speaker 1 (00:28:48):
And here the responses started from day one with laparoscopic surgery automatically. That tells me so much because it’s not infection, it’s not a Mesh reaction. It could be meshoma direct injury. There’s so much that is possible. Or you may just be one of those people that you know can have a cord lipoma that’s that’s kind of retained and so on. So you need to see someone who’s thoughtful that sit done, all the names that you mentioned have been guessed. So go back and watch all of them discuss chronic growing pain and pick a great surgeon for yourself. Okay, next question. Additional thought along with weight loss, smoking cessation and therapy for one forward to surgery is another step which can be taken. Dr. Ramshaw had that as his presurgical patient involvement. Yeah, pre prehabilitation, right? That’s something that Bruce Ramshaw started and he was one of our first guests, and he’s no longer clinically active, but he’s continuing to advance hernia care by promoting rehabilitation and really streamlining care for patients. Okay, here’s another question. I have three hernias, but the one that causes me the most problems is my umbilical hernia, which I had stitched last year as I refused Mesh due to Mesh causing blocking of my bowels a few year, few years ago, which has now come undone inside. But a CT scan revealed my stomach muscle has now separated, leaving my bowel only covered by a thin layer of skin. What are my options?
Speaker 2 (00:30:38):
So this can happen, which we call a hernia recurrence. So you’ve had a surgery before fixing the, attempting to fix the hernia, and since then the hernias come back. And so I think depending on the size of the hernia and most of the research in the literature that exists in the hernia world, we talk about hernia recurrence. And generally in most of our practices, I think if a hernia is over about 1.5 centimeters or if it’s a recurrent hernia, we do recommend the use of Mesh. But I would say that Mesh is different, not because of just the quality of the type of Mesh, but I think it’s also really important where you put the Mesh. Yes. And so I think if you’ve had prior issues with Mesh, it may not have just been the Mesh itself that was causing the problem. It may have been where the Mesh was placed.
Speaker 2 (00:31:32):
Correct. And it sounds like if the hernia has come back and it’s a little bit larger than it was before, I probably would not recommend just repairing it with sutures alone, especially if a surgery like that has previously already failed. Because that to me says that if we try to do the same thing again, the chances of success are low. And so probably if you were seeing me in the office, I would probably counsel you on a Mesh repair. And depending on what the CT scan looked like and how big the defect was, it might be possible to do a minimally invasive repair robotically or an open operation. But I think the key to doing the surgery would really be to place the Mesh in what we call an extra peritoneal plane. I like to kind of talk about the muscles like pillows and the connective tissue around the muscles like pillowcases. Oh yeah. I love that. Yeah, I know. Do you like that analogy? Yeah,
Speaker 1 (00:32:26):
I’ve never heard of that way. That’s
Speaker 2 (00:32:27):
Good. Yeah. So when I talk about placing the Mesh, I place it actually on the inside of the pillowcase, right against the muscle on the underside. So when we stitch it back together and stitch the hernia and the connected tissue and the muscles closed, what ends up happening is that Mesh actually ends up sitting in a layer of your abdominal wall and it doesn’t really come into contact with any of your internal organs and should really cause very minimal interaction or scar tissue from that sense. So I do think Mesh is great depending on how you use it. But I agree that not all Mesh sometimes is used well, which is why, you know, end up seeing some of these complications. Yeah,
Speaker 1 (00:33:07):
I feel like
Speaker 2 (00:33:07):
I
Speaker 1 (00:33:08):
Do think, yeah, I feel that people have complications with their meshes and it’s so easy to blame the Mesh, whereas potentially if a different technique were used with the same exact Mesh, then the outcome would’ve been better and there wouldn’t be as much of a Mesh problem. I’m not denying that there are aren’t Mesh problems for sure. Mesh as any implant has its complications. But if you had a blockage from Mesh, then that implies to me that the Mesh was placed against the bowel or somehow exposed to the bowel. And there are many other techniques that are safer and more effective than that kind of placement. And like you said, just stitching a, each time you stitch a failure, it fails more often. The first time when it fails and you stitch it, then the recurrence rates around 50, 60%, then the recurrence goes up to 60, 70, 80% each time. And then sometimes you end up with these enormous hernias. Have you seen these giant hernias? And if you ask the story, it was started as a little belly button hernia and it kept tearing. They’d stitched it in the tear again, et cetera. And so multiple failures later now they have these giant hernias which are very, very complicated to treat.
Speaker 2 (00:34:26):
Actually, the other point I’ll make about these umbilical hernias is sometimes that I think there’s a concurrent diastasis along with that umbilical hernias. Yes. So if you ever have a separation of your rectus muscles, like pregnant PA patients do, where that sort of comes to come back together. But I think what happens sometimes is only the umbilical part of the hernia gets F fixed, but the diastasis is still there. And that diastasis, even though it’s not a hernia, it’s a thinning of your abdominal wall along that area, that leads to some weakness. So if you think about this defect and then this diastasis, if you just stitch together one area, but the other areas are still weak, sometimes I think the hernia can occur either above or below that sort of along the progression of that diastasis. And so my preference for fixing these actually in patients with the diastasis and umbilical hernia is actually to do a robotic repair. So I’ll sort of get into a layer of the abdominal wall kind of in the underside of that pillowcase, so to speak. I’ll suture the diastasis and the hernia together and then put a Mesh in that layer of the abdominal wall and just close up everything. So there’s no Mesh that comes into contact with anything. But at the same time, you’re sort of strengthening everything along the midline.
Speaker 1 (00:35:42):
Well update, she’s had seven different operations,
Speaker 2 (00:35:45):
So she’s,
Speaker 1 (00:35:48):
She’s one of those patients where people like you who build a center, and I assume you have different specialties and different specialists to handle something like this because she’s not someone, you just kind of go to your local general surgeon to repair a hernia. You need multidisciplinary approach. Make sure Dr. Teems, what did you call it? The risk factor clinic?
Speaker 2 (00:36:16):
Oh yeah. It’s a pre-opt optimization clinic. Pre optimation
Speaker 1 (00:36:19):
Clinic. Yeah. Reduce the risk factors clinic can get there to get towards a much better outcome. Because let me tell you, seven operations, first of all, that’s horrible. I’m sorry about that. But you don’t want it to be number nine and 10, 11, 12, you just want number eight maybe. And then the kind of, that’s it. And that only really happens in a specialty center where you have multiple different specialists that can address one problem. Okay, here’s another one. I had six hernia pairs last year, not what we went in to see. Mesh was put in. I haven’t been the same. I have another femoral hernia. I feel my pelvic floor is weak when I have bowel movements, I have stabbing pain in the groin, like something sharp. I’m getting opinions in New Jersey, but I don’t feel the approach will help me. New jersey’s another one. We don’t really have a lot of specialists there. I don’t want to be worse, such as neurectomy, cutting nerves and putting in more Mesh six hernia pr. It sounds like she had six hernias, maybe like bilateral hernias.
Speaker 2 (00:37:29):
Yeah. So I wonder if her pelvic or that inguinal floor area was just weak in general. Yeah. Does this attendee say whether or not this was done open or minimally invasively
Speaker 1 (00:37:43):
Doesn’t say she follows up with, my life has changed for the worst. Last year, my doctor sent me for physical therapy in November, not knowing I had a hernia or hernias. And it seems like that made me worse too. I was sent to physical therapy last November. It made my groin pain worse. I also have Sjogrens, which is an autoimmune disorder. I was told the Mesh is on the top layer, but I feel like something sharp in my groin. I’m also getting muscle and pain since I had my surgery in the groin. These are complicated, laparoscopic, looks like she had done laparoscopic. So sounds like a laparoscopic Anglo hernia repair in someone with an autoimmune disorder in multiple hernias and maybe also a known pelvic floor disorder. There’s there’s multiple things happening in one patient.
Speaker 2 (00:38:31):
Yeah, that’s really complex. And I think at the end of the day, it’s really hard to generalize hernia care, right? Yes. And so I think that’s why going to a specialist is so important in some ways is because they’re going to have seen a lot of different presentations of the same type of illness because complications after hernia surgery while they do happen is not the norm. And so if all the complications and the complex patients are going to very specialized places, then all of a sudden you have a collection of hernia surgeons who just have a lot more experience dealing with the complex things. And I think sometimes having somebody take a look at your case who’s really familiar with chronic groin pain or having it
Speaker 1 (00:39:19):
Takes the time
Speaker 2 (00:39:20):
Or doing redo operations and really takes the time to listen to where your pain is and to do the diagnostic testing is really important.
Speaker 1 (00:39:28):
Is there a Yeah,
Speaker 2 (00:39:29):
I’m sorry. That sounds like a lot.
Speaker 1 (00:39:32):
I know. But listen, those of us that like to do it, we actually enjoy the challenge. But chronic groin pain in particular is not one of the fancy parts of doing hernia surgery. These big abdominal reconstructions that you do are actually much more fancy robotic surgery and so on. Those of us that just little around inside the groin with little nerve here and there, little meshoma here and there, we enjoy what we do. But it’s not as granular,
Speaker 2 (00:40:04):
It’s not fancy. I mean, I think all hernia surgery can be fancy or not fancy, but I do think the inguinal hernia is a lot more complex than most people give it credit for. I have a lot of resonances coming to do inguinal hernia surgery, and a lot of them feel like, oh, it’s an intern operation. But really the anatomy and how you have to think about the groin is very complex and it’s so different from the anterior open side versus the posterior. So I think there’s a lot of little nuances and a lot of little details that people tend to, I don’t want to say miss, but maybe they don’t pay attention to as much. And so I think true that during the initial operation, paying attention to all these small little details is really critical. And I think maybe that’s just a failure of teaching across the board of how do you approach these in certain ways. So I think that that may be part of it too.
Speaker 1 (00:41:03):
Someone’s asking if there’s a hernia specialist in Minnesota. Well, Dr. Ramaswami just left.
Speaker 2 (00:41:08):
Yeah, Ramaswami in California. Did she really? Oh, yes, yes. Oh, I didn’t know that. I didn’t talk to her about that. Ok.
Speaker 1 (00:41:15):
From the VA now at, she was one of our guests too. She’s at the VA now at Loma Linda, so we’re happy to have her. Oh
Speaker 2 (00:41:21):
Yeah. It’s hard to cause of California. I mean, yeah, I get it. Minnesota. Minnesota is very nice though. I wonder if there’s anybody at the Mayo Clinic that does complex hernias. I think I have to think about a couple people.
Speaker 1 (00:41:36):
But yeah, so Megan,
Speaker 2 (00:41:37):
I wonder if that would be a place.
Speaker 1 (00:41:39):
Yeah,
Speaker 2 (00:41:39):
Megan Nelson.
Speaker 1 (00:41:40):
Yeah, Megan Nelson. We had her on as, and she has a handful of colleagues. Mostly they do abdominal wall, not so much groin chronic pain, but yeah, that they’re right. Mayo would be an option. Let’s see. Here’s the one, same situation, but I ended up having Mesh removal and very little relief after removal. I actually was given a referral to University of Michigan. Oh,
Speaker 2 (00:42:10):
Great.
Speaker 1 (00:42:10):
But when I called, they wouldn’t see me without a diagnosis. Very frustrating because the diagnosis is what I’m looking for. How could you help with that? What are your thoughts on that? Is that
Speaker 2 (00:42:21):
Yeah, asking referral. Asking for a referral. So I think having your primary care doctor make a diagnosis, and it doesn’t have to be a very specific diagnosis. I think it could be something like chronic growing pain, or if you have imaging that says you have a recurrent hernia, even just hernia recurrence I think would be great. I do know that at the University of Michigan, as I’m learning this now, we do have certain access issues. So sometimes I feel like patients are waiting a little bit longer to get scheduled to see a physician. And so that is something that I do think can be a little bit of a problem. But I would have your primary care doctor reach out to somebody, let us know your story. Usually I try to keep a couple of clinic spots open for patients who need to be seen more urgently or who have been waiting a long time. So I think it’s a matter of having somebody reach out to us. I think all of us are more than willing to help in any way that we can. But if it’s a matter of making a diagnosis, I think on the referral, whoever’s referring you, if you, it’s your primary internal medicine doctor, I would have them just, if they don’t know what the diagnosis is, do growing pain after inguinal hernia surgery, I think. Right.
Speaker 1 (00:43:33):
You don’t need an accurate diagnosis. You want ’em, a description is fine. Growing pain or Yeah, something like that. Yeah, you don’t have to have an accurate diagnosis. The description alone is fine. Okay. Good. People are willing to travel. I think one of the things that has been great has been telehealth and that in addition, people are willing to travel. So there are people here that are saying they’d be willing to travel to go to others like Dr. Krpata and so on, who you mentioned. They actually have a system where they have a multi-specialty clinic where you see multiple specials at one time to help figure out chronic groin pain. And then going back to the lady who had the laparoscopic six hernias and pelvic floor disorder, she’s being seen by a pelvic floor reconstructive surgeon. What are your thoughts of urogynecologist gynecologist, urologist and how they relate to abdominal wall problems?
Speaker 2 (00:44:39):
So actually when I was at Penn, one of the surgeons that I worked with, Dr. Heidi Harvey, she did a lot of pelvic reconstructive surgery. And I think sometimes you can have interrelated disorders. And I think the hard part is we just don’t know very much about it, right? Because it’s a functional issue. And I think as surgeons and as physicians, we really have a hard time figuring out how to fix functional issues. And I think sometimes pelvic floor disorder, some of that stuff, all of that sort of interrelates. And I think at the end of the day, the truth is that I don’t think we have good solutions for some of these disorders sometimes, right? Sure. And that goes along with functional GI issues that goes along with pelvic disorders. And sometimes I think we just haven’t really maybe pinpointed something that would necessarily help.
Speaker 2 (00:45:34):
And it may be a combination of medications, physical therapy, alternative therapies and surgery, or maybe not even surgery. Sometimes I think for certain patients, surgery actually makes things worse. And the last thing that I like to do is tell somebody that I don’t have a surgery that I can offer them. But I think most surgeons are very honest. All of us want to make our or our patients better. So I feel like if somebody’s coming to see me and very specifically for their problem, if I don’t think I have a surgery that can necessarily make it better, oftentimes I wouldn’t offer surgery because the last thing you want is to make things worse. And then all of a sudden, you know, have Mesh in your pelvis and now it’s very confounding. Right now you don’t know, is it the Mesh cause the problem?
Speaker 1 (00:46:25):
Yeah.
Speaker 2 (00:46:25):
Is it the Mesh that’s causing the problem is, was it my original diagnosis that was the problem. So I think when you have an operation, it’s very important to have an operation for a very specific reason and a very specific problem that you’re hoping to make better. And sometimes I think with functional issues, it can be very difficult to predict what the outcomes are going to be.
Speaker 1 (00:46:49):
Yeah. One thing that some people don’t understand is Mesh does not stretch and actually becomes quite stiff in many people. In the meantime, we put it against a lot of areas which need to stretch or want to stretch. Pelvic floor is one of them. You have intestines and you have the actual pelvic floor muscles, you got ureter and a bunch of other organs nearby. If you put Mesh against uterus, no one cares. Uterus doesn’t move, but the put it against the colon, that’s a different story. Same with the abdominal wall. Too thick of a Mesh we learned is not good. It’s like armor. Yeah. Too thin doesn’t really help that much either. It’s better than too thick. And so on that note, here’s a question. I have two meshes from incisional hernias. After a 2015 ruptured appendix surgery, is it difficult to go in and cut through the Mesh to repair what I now have, which is a mobile sequel? And then how is the Mesh repaired afterwards? It’s a great question because if someone’s had, let’s say, a really good incisional hernia repair abdominal wall with Mesh, now they need another operation. How do you get around that?
Speaker 2 (00:48:02):
Yeah, that is a great question. So I think it depends on what kind of surgery you’re going to have. So sometimes when you’re having a bowel resection, which is typically what we do for a sequel, right? I don’t know that anybody really recommends pexying or just suturing down. Most of the time we recommend taking out the right part of your colon and putting things back together. So usually that’s a contaminated case because we’re opening up the bowel and we don’t like to put fresh or any type of Mesh in that situation. But if you already have Mesh, I would recommend that if everything looks good and there’s minimal contamination, is to close that Mesh with prolene sutures. Because what ends up happening is once you cut the Mesh, because it’s an enaminate object, you cannot use any sutures that will absorb in the abdominal wall because then that Mesh doesn’t grow back to itself like your normal abdominal wall would. So generally, anytime you have an operation where you’re going through Mesh where the fields are fairly clean, I would recommend using a permanent suture to reapproximate that Mesh and sew it back together as the surgeon’s closing the abdominal wall. But sometimes if there’s high risk for infection, I think an absorbable suture is still the way to go. It’s much better to unfortunately get a hernia recurrence than to have an infection complication because that can really be,
Speaker 1 (00:49:24):
Yeah, I would say the first goal is don’t go through the Mesh. Right? Try. I mean, sometimes a good CAT scan, you can tell and an opera report, the combination of the prior obturator reports and the CAT scan, you can kind of figure out the borders of where the Mesh may be. And if you’re kind of a laparoscopically skilled surgeon, you should be able to sneak around the edges. It’s not easy, but it’s more difficult operation. But try and do the surgery without going through the Mesh. That would be, I think, first choice. But if, like you said, if you have to go through the Mesh, number one, you’re at risk of infecting the Mesh, especially in a complicated, what do you call it, a contaminated situation like a bowel surgery that this person is talking about. And number two, you’re at risk of having a hernia where you entered through that Mesh, which is why that it’s important to close it. Unlike normal abdominal wall, you have to close it like Mesh on Mesh abdominal. But that’s a good point. Very good point. Here’s another question. Does having a prior open repair, which includes some sutures connecting the rectus muscle to the pubic tubercle and inguinal ligament as part of a sport turn repair, boost the patient with a sport hernia repair, does that prevent a successful TEP approach by interfering with the blind retro rectus dissection?
Speaker 1 (00:50:55):
So this is an open sports hernia repair and now they’re doing a TEP surgery of some sort? I don’t see a problem with that.
Speaker 2 (00:51:03):
Yeah, I think it would be fine. I think it’s going to be very surgeon dependent. a lot of times when patients have had some sort of growing operation, I tend to just do a transabdominal pre peroneal approach. Yeah, because I just think it’s a little safer because I don’t know what’s been done and I don’t like to do a blind dissection, but I don’t think there’s anything wrong with it, especially if that posterior plane has not been previously violated. Correct. Nobody should have been there before and it should be fine. But sometimes, and I think with the previous operative report, if we’re certain with the kind of Mesh that was placed that there’s no Mesh plug in there, then it should be fine. Yeah.
Speaker 1 (00:51:45):
This is true question. Can a CAT scan be performed if I have a spinal stimulator in place?
Speaker 2 (00:51:54):
Yeah. Yeah. I think it depends on what it is, but I suspect it should be fine. I think the device should come with like an MRI compatibility document, right?
Speaker 1 (00:52:06):
Yeah. MRI for sure. Some of them are not MRI compatible, but CT scan it
Speaker 2 (00:52:11):
May. Oh, CT scan for sure. Yeah.
Speaker 1 (00:52:13):
Yeah. It may distort your picture sometimes cause in interference, but CT scans pretty much stay for anyone. You don’t have to contrast. So in that way it has radiation, but otherwise it’s safe. It’s the MRI that moves things around that are metallic. And you have to be careful that any implant you have is MRI compatible. That includes pacemakers, joints, clips in the brain. We are dental implants and then of course a spinal stimulator. Okay. Another question. Can you please explain the issues of suturing Mesh to Mesh and how it holds? Maybe repeat what you said earlier.
Speaker 2 (00:52:56):
Yeah. I generally think that you can suture Mesh to Mesh. That’s fine. So we use many different types of sutures during surgery. Some of them are permit, meaning that they don’t absorb over at all and they are just there forever. And then some are more absorbable, meaning that over periods of time that’ll just naturally dissolve. And so when you’re suturing Mesh to Mesh, you generally want a permanent suture that doesn’t go away because the Mesh isn’t going to grow back to the part of the Mesh that’s already been cut. Whereas your skin, your tissue will heal and grow together, which is why we can use absorbable sutures.
Speaker 1 (00:53:33):
That’s a really important detail that the, I’m willing to bet the majority of surgeons are not aware of that because they sometimes don’t think, and they’re operating on someone who’s had Mesh repair, they cut through the Mesh, which is fine. Ideally you don’t want to do that, but let’s say you have to. And then when they’re done, they close the abdominal wall, they close every single other abdominal wall and it’s just not the same because now you have Mesh. So if you close it like a normal abdominal wall, guess what? You’re going to get a hernia. Whereas if you understand that there’s Mesh there, and I tell my surgeons or urologists, let’s say, well, you got to use permanent suture. Oh. Oh really? Oh, oh yeah, great. Thank you. It’s like a light bulb went off like, oh, you’re so right. I wasn’t thinking about that. But it’s just these are little things that make a big difference that a hernia specialist who’s done this before understands and maybe a general surgeon or a non hernia, any other specialty may not be aware of
Speaker 2 (00:54:40):
For that. Yeah, the devil’s in the details. It’s always it’s,
Speaker 1 (00:54:44):
Right. Yeah, exactly. We had some questions that were submitted ahead of time, so we have a couple more minutes to go through that. This is an interesting question. How would you compare hernia treatment outcomes between medical centers that implement a volume-based approach to hernia treatment and those that are focused on a personalized approach while treating fewer patients? Good question.
Speaker 2 (00:55:09):
Yeah, that is a good question. So I’m not sure that those are mutually exclusive to be quite honest with you. Sure. Because I think the way I would think about this is that a lot of times when we talk about high volume centers, it means that probably seeing a lot of disease pathology in complex patients. And so I think that when you talk about a high volume center, they’re going to have more resources in place for complex hernia care. And I think that because they see so many complex patients, they’ll provide a more personalized approach for each patient. And I think that when you go somewhere that maybe you’re treating for your patients, that can still be the same. I don’t necessarily know that those are mutually exclusive principles.
Speaker 1 (00:56:01):
Yeah, I would add to that. Exactly. So they’re surgeons in my town and institutions, all they do is hernias. They’re outpatient primary hernias. Anyone that’s a little bit complicated, they send to me and they do great. Right? Primary low risk patients, they’re not obese, they’re not multiple recurrent, they do open and laparoscopic surgery and their patients do well and I never see any of their complications. Or there are people that are not high volume, but they’re low volume. I would consider myself low volume. I don’t do thousands of cases. I spend a lot of time with each case there. Every single case I do is somehow complicated. I don’t have that practice where I’m just churning a cute little belly button five times a day. That would be fun, but that’s not what I inherit. So there’s something to be said about surgeons that specifically treat the complications because you learn from, it’s like an, it’s like a forensics, right? You learn from other people’s complications and makes, I think that makes you a better surgeon too. But yeah, I agree with you. High volume is always good, but there are situations where you’re, you’re a high volume generalist, which means we have Kaiser, I don’t know if you have a Kaiser in your part of the world. We have what’s called Kaiser. It’s like a closed system managed care, and it’s just high volume. It’s like a socialist, they call it like a communist situation.
Speaker 1 (00:57:53):
No specialists, they’re general surgeons. They all do a good job, but you know what? They really don’t care about gallbladders and hernias and so on and lipomas. What they do, and I’m not sure most of ’em really have any interest to specialize in it. They’re happy with what they’re doing, and they’re probably doing the same hernia repair that they were treat taught in their residency 20 years prior and not change the thing. So that may or may not be a good thing, right. But yeah, it’s hard to generalize that question is it is trying to generalize the situation and it’s hard to do that. Okay. One more question and then we’re going to call it quick. I had an incisional hernia repair after a right-sided hemicolectomy. The first repair failed, so the surgeon put a second Mesh a larger one 15 by 20 centimeters on top of the smaller piece. Should the smaller piece have been removed first, what do you do about recurrence and what do you do with the prior meshes?
Speaker 2 (00:59:01):
Yeah, that’s a great question. Yeah. So when somebody comes to see me with a recurrent hernia, they already have Mesh in the abdomen. I think it kind of depends on what’s going on with that Mesh. So if there’s something very obviously wrong with it, obviously an infection on the CT scan, I can see it’s folded up sometimes in recurrences. We see this phenomenon of what I call Mesh, where it’s sort of in the center where the hernia is, but it’s not really doing anything. So sometimes the Mesh just has to come out. But sometimes when I get in there, I find that the Mesh is very well incorporated in the layer of your abdominal wall where I feel like it’s not infected. It actually looks perfectly fine and it would actually do me do the patient more harm for me to take it out than I plan to just leave it and sort of take it down along the layer of the abdominal wall and just put Mesh on top of that area.
Speaker 2 (00:59:52):
So I think it depends on really what the Mesh looks like and whether or not I feel like it needs to come out. Yeah. Because I think for some of these redos, sometimes leaving that old Mesh is fine if there’s nothing wrong with it and it’s well incorporated. But other times I think it has to come out in order for the hernia repair to be successful. And I think it just kind of depends on what it looks like at the time of surgery. And so usually I’ll tell patients if the Mesh looks like it needs to be removed, I’ll definitely do it at the time of the surgery. But if I feel like it looks great and I, there’s nothing necessarily wrong with it and it’s well incorporated, it may be actually better to leave it than to take it out and maybe cause some damage to certain tissue planes.
Speaker 1 (01:00:37):
Yeah. Yeah, I agree with you. It depends on where the prior Mesh was. If it’s a totally different plane, then there’s almost never a reason to remove that. The only question is Mesh on Mesh, and like you mentioned, Mesh doesn’t scar onto Mesh itself. So Mesh on Mesh usually does incorporate very well unless there’s a lot of extra tissue or something in between. So the tendency is to try and start afresh, but the risk is causing more harm. So if that involves removing Mesh and therefore you have less tissue to work with or it’s going to be a worse outcome than obviously that would be not something you’d want to do. But in general, do you agree Mesh on Mesh doesn’t work? You need Mesh against healthy tissue?
Speaker 2 (01:01:33):
Yeah, no, I do agree. So I think it depends. I think in the Retrorectus plane or sort of extra peritoneal plane, I think it works okay because most of the meshes we’re using are fairly large pour and I think you get pretty good tissue and growth. So if that’s kind of what was placed there before and that’s what you’re using, again, I think in that case you might be able to get away with it. But depending on the kind of Mesh that was there before, I’ve definitely had certain types of meshes where I get in there and it’s some sort of coded Mesh or there’s a layer where I know it’s not going to incorporate very well against anything. Those are the meshes that I end up taking out. And those don’t really incorporate very well to begin with. Right. Yeah. And so I agree with you. Putting Mesh on Mesh in certain areas I think can cause seromas and just fluid build up of things and just a fluid layer between the meshes. So I think it really kind of depends on where the Mesh is placed, what kind of Mesh it was, and how well it’s sort of incorporated into your abdominal wall. Sometimes you can tell on a CT scan, but sometimes you really have to get in there to see it in order to figure out what’s going on with
Speaker 1 (01:02:46):
It. Yeah. Yeah, I agree. Yeah, I’ll see little things that we think about before we operate. There’s so much to think about. Well, my friend, we’re done. We are done.
Speaker 2 (01:02:58):
This was so fun. Your patients are so knowledgeable. Oh my God, I feel like it was kind of like hernia clinic.
Speaker 1 (01:03:05):
They’re so knowledgeable. The questions are so smart, and I just love doing this every week, and I’m really very grateful to have you as my guest. Thank you so much for agreeing to doing this. We’re all so busy and we just came back from a big meeting, so I appreciate your time on that. So thanks very much for joining me.
Speaker 2 (01:03:25):
Yeah, thank you so much for inviting me. This was a lot of fun. I’d be happy to come back anytime. Thanks. And yeah, I’m definitely going to be watching some of these episodes and past episodes of your Hernia Talk podcast. This is really great, and I’m so glad that your patients have you to provide this resource for them. I think this is patient education is always very valuable.
Speaker 1 (01:03:47):
Thank you. I’m grateful to you, the experts to help make this better. So thanks everyone. Thanks for joining me. That’s another episode of Hernia Talk Live. Join me next week with another great guest. Don’t forget this episode in all prior episodes will be on my YouTube channel at Hernia Doc. You can catch up with all those other doctors that we mentioned as well. And thanks for everyone for following me at Hernia Doc on Twitter and Instagram and at Dr. Towfigh on Facebook. And I will see you again next week. And Jenny, I hope to see you soon at one of the other meetings.
Speaker 2 (01:04:25):
Yep, you too. Bye. Take
Speaker 1 (01:04:27):
Care. Thank you. Bye.
