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Speaker 1 (00:00:10):
Good evening everyone. It’s Dr. Towfigh. Welcome to Hernia Talk Live. We’re here again on a hernia talk Tuesday night. My name is Dr. Shirin Towfigh. I am your Hernia and laparoscopic surgery specialist. Thanks for everyone who’s joining me on Zoom as Live and also as a Facebook Live. You could follow me on hernia at Hernia Doc on Instagram and X, but most importantly, I do want you all to subscribe and follow me on my YouTube channel where all of these episodes and prior episodes are archived. We’re also on as a podcast if you prefer to listen to Hernia Talk Live as a podcast. So we got tons and tons of great content for you. So I’m really excited because Clay Petro, Dr. Clayton Petro is our guest today. He is a very lovely surgeon, part of the esteemed Cleveland Clinic hernia group. He is one of their Hernia surgery specialists in Cleveland, Ohio, and I’m super excited and you’ll know just why once you hear him talk. Thanks so much, Clayton, for joining me.
Speaker 2 (00:01:18):
Yes, absolutely. Thank you for having me. I’m honored to be here.
Speaker 1 (00:01:21):
Thank you. So Clayton’s one of the younger surgeons that I have the pleasure of having, but I felt that I was very impressed by your empathy for both the surgeons and the patients. We were recently in Cleveland, in your hometown for a course. We were teaching for the fellows that are in training to do laparoscopic hernias and minimally invasive surgery and so on. And what did I talk about? I think I talked about, I think going into private practice, you gave this really amazing talk about handling complications because as someone graduates from their training, now they’re responsible for the complications that will occur. Every surgeon will have a complication. There’s the old saying, right? If you have no complication, either you’re not operating, you must not be operating because all surgeons will have a complications. You can’t not have it, but it’s very humbling. I recall my first complication, I was a county employee, so I was at the county USC, and I think back in it, it is just so funny.
Speaker 1 (00:02:38):
So I did a laparoscopic cholecystectomy, right? Gallbladder surgery, a very routine surgery. Everyone who graduates from their general surgery should be able to do a good gallbladder surgery. And at the county hospital, that’s all you were doing. Pretty much like 80% of the operations were gallbladder surgeries. And my first complication was a bio leak and I was junior. Everyone was in their fifties or over in my group, and I was just hired right out of residency. And they had our own little group, m and m, and I had to expose myself. I felt like exposed that I had this complication. I literally thought the world had just ended and I’m just going be labeled as the worst surgeon ever. And for most of you, if you don’t know, a bio leak is, I mean, it can be a disastrous problem. In this case, it wasn’t.
Speaker 1 (00:03:38):
It was just like a little kind of leak or something. We didn’t even have to do anything for the patient. It just stopped on its own. The lab tests were abnormal for a couple of days and there was a little fluid, everything else was normal. But to me, I felt like a failure. I felt like there’s going to be like, wow, look at her. She just came out of residency and already she’s causing complications, which of course wasn’t the situation, but to me in my little world that was, I felt really exposed. So you had that experience too. Everyone has
Speaker 2 (00:04:16):
Conversations. Oh, absolutely. Yeah. I mean, I started my career at the main campus of the Cleveland Clinic,
Speaker 1 (00:04:22):
Oh boy.
Speaker 2 (00:04:23):
At a time where a lot of the senior staff had left to take leadership positions at other hospitals, and the department was kind of turning over a little bit. And so we were taking a lot of call. They hired me and the HPV fellow the same year, and we were both new staff taking a lot of call. And so you can imagine the types of cases that the main campus of the Cleveland Clinic attracts. No one has a straightforward anything
Speaker 1 (00:04:51):
Have. They travel for all your work.
Speaker 2 (00:04:53):
And in the straightforward cases, they’re either a hundred years old or they’ve had a heart transplant or something. Everyone has something. It’s never just an appendectomy or just an inguinal hernia. It’s always got something else going on with it. And same thing, I mean, I remember the first inguinal hernia I fixed was, well, not the first one. The first complication I had was on a patient who was like 98 years old, inguinal hernia, and he aspirated in the recovery area.
Speaker 1 (00:05:27):
So basically the stomach contents laying in the lung. And that’s really devastating for an older patient.
Speaker 2 (00:05:35):
Older patient ended up in the ICU. And so that was again from
Speaker 1 (00:05:40):
An inguinal hernia.
Speaker 2 (00:05:41):
From an inguinal hernia. And again, this is, it’s hard. And I think the hard part, and the reason for talking to the fellows too is just you are the person. It’s related to surgery or not. Anything that happens to your patient while they’re in the hospital, you’re the point person and the family’s waiting to hear from you. And that was part of my talk was in talking to the fellows, was to make sure they understood that family in the waiting area, whether it’s related to surgery or not, they’re waiting to hear from you and you need to see those patients multiple times a day because nothing is worse when a patient’s going through a complication than when the surgeon retreats. And I think that we have to recognize that as surgeons and those are the patients that you need to, the patients need to be able to get a hold of you. And so oftentimes when I was a junior, I took that to heart and maybe I even took it too far and I would give those patients my cell phone number. And from the first couple of years, I think the story I told before was I gave patients my cell phone number, and most patients are respectful of that.
Speaker 1 (00:06:57):
They They really are.
Speaker 2 (00:06:58):
Yeah, they really are. I’ve actually been shocked. Like most patients, if there’s an issue, I want them to be able to get a hold of me because big hospital system, particularly like the Cleveland Clinic, you’re getting into a call tree and it might be hard to get a hold of someone. And there’s, when someone has had a complication, I feel like they deserve a little more access. And most patients take it to heart. But there have been people who they’re a call and a text away all the time it seems. But yeah, that was the gist of what my talk was about was just making sure that patients know that you’re there for them, particularly when they have a complication. Because if you see a patient through complications happen, it’s just part of surgery. And I know patients sometimes don’t like to hear that, but the truth is that any operation, even no matter how routine things happen, and I think it’s important to when they do happen, that you need to own it. And the goal is to get them through the complication and every complication has an end, and your job as the surgeon is to get ’em through it and see it through.
Speaker 1 (00:08:05):
And I think, so what I liked was that you actually addressed it. That’s not a topic that’s usually addressed with trainees. But also you brought in the patient perspective too. Maybe you can talk a little bit about the patient perspective and your touch with that.
Speaker 2 (00:08:24):
I’m not sure exactly. I think I know what you’re talking about. So hopefully,
Speaker 1 (00:08:30):
How do patients maybe, do you think they perceive complications and how should a doctor handle that?
Speaker 2 (00:08:37):
Yeah, I mean, the assumption is that sometimes from the patient’s perspective is that you did something wrong, you must have left the operating room and something was wrong and you missed it or you did something. And that depending on the medical literacy, that is hard to convey sometimes that, listen, when I was there, everything looked okay. I did all the maneuvers that were necessary to make safe, but sometimes things happened and that could be really challenging. And then the other kind of thing is just from the patient’s perspective is most patients when they have their surgery, they envision what the recovery is going to look like. And they have these kind of checkpoints in their mind of, I’m going to be in the hospital this much time. I’m going to out of work this much time and I’m going to be back at work and I’m going to be a hundred percent by this day.
Speaker 2 (00:09:31):
And so when complications happen and that timeline gets disrupted, not only can it be frustrating for them, but the domino effect of how that can impact their life. We often don’t always completely think about in terms of all of a sudden they were planning to be back at work at four weeks and now it’s six weeks, and they may not have that PTO, and there’s a financial consequence that may not just be the hospital bill, but just the time that they took off work that they weren’t planning or they had childcare arranged for this many days and now it’s going to need to be longer. Or maybe there’s someone that takes care of a parent and they are hiring someone else that has to do that role for them. So there’s so many domino effects that we don’t always think of. And so I think it’s an important thing when we talk to patients of explaining like, Hey, listen, in a perfect world, this is the recovery, but these are X, Y, and Z things that can happen that may delay that recovery as well.
Speaker 1 (00:10:33):
How do you talk about complications? So for me, I do go over complications, but if something’s really, really rare like death, I don’t usually talk about death and an anal hernia. My patients tend not to die. I’m just not that person that’s doing these really sick patients or highly emergency operations. It’s mostly elective. I mean, I’m happy to do them, but that’s not usually what I do. But then what if you do have a death or you do have a really bad complication, do you ever feel like, does that mean you want to talk more to patients about all the complications? I feel like I don’t want to stress them out with, because I understand the relative importance, but they may not understand relatively speaking, what’s important, what’s not of all the complications.
Speaker 2 (00:11:26):
So I agree with you. I don’t bring up death because I do think, and I could be wrong, but I think that there is just a common understanding that any operation carries a small risk of something horrible happening. And I think in lay terms, most people appreciate that. I think what I talk most about are things that are most common to our operations that people may not necessarily think of. So I think if do something at a high volume, and there are specific things that patients probably aren’t aware of. So a perfect example of this, in my world, I do a lot of big open abdominal wall reconstructions and those are folks that need a big laparotomy. Often I’m taking old mesh out because people have had 2, 3, 4, 5 repairs and I’m doing it for the final time once and for all. And so one of the most common things that happens after these repairs is an ileus. That’s probably the most common complication for those who know an ileus is delayed bowel function. And it means you throw up because you haven’t passed gas
Speaker 1 (00:12:27):
Cramping
Speaker 2 (00:12:29):
And you get a tube in the nose, which is absolute most miserable thing in terms of recovery. In our practice, it tends to be 10, 15% of folks. So it’s not infrequent. So I bring that up because when it happens on the third day and it prolongs their hospital stay by three or four days, and they’re sitting there with that tube for the third day and they haven’t passed gas or had a bowel movement yet, they’re looking at you like, what’s going on? I should have been home by now. And so I have learned that that honestly, that’s the moment. And I know that tube’s going to come out, they’re going to pass gas, they’re going to have a bowel. You see the
Speaker 1 (00:13:08):
Light at the end of the
Speaker 2 (00:13:08):
Tunnel. I know they’re going to be fine and in the long run, but they don’t know that. And so I have started to even bring that up in my office that, Hey, listen, there’s a chance this can happen. It’s not the end of the world. It doesn’t impact your repair. And so that’s a perfect example of something that I bring up in the office just so they hear it. Usually I want their family to hear it again. They’re the one that is like, gosh, I thought they were going to be out of there by now, and now they’re here a little longer. But wound morbidity, I’ll comment that our wound infection rate is somewhere around three or 4%. And that very rarely does that require going back to the operating room and even if it does in the vast majority of cases, doesn’t impact the long-term durability of your repair. And so those are probably the two big things. I don’t bring up transfusion, kind of what
Speaker 1 (00:13:59):
Transfusion, yeah.
Speaker 2 (00:14:01):
Yeah. I mean that’s maybe something I bring up in the moment in the instance when it’s necessary.
Speaker 1 (00:14:08):
Yeah. Here’s a question. It says, how do you address a situation where a patient seems to be worsening over time?
Speaker 2 (00:14:15):
Yeah, so that’s a little vague, but I’ll kind of say, I think in a scenario where, let’s say again, I’m trying to think of a scenario. So let’s say someone has a respiratory trouble a couple days after surgery and they’re getting transferred to the ICU and now they’re, again, I think with any complication, particularly if the patients are, let’s say, intubated and sedated in the ICU, it’s you and the family and it’s you and that family is relying on you for updates. And it’s really just about open lines of communication, honesty about what the trajectory is, honesty about when you’re not sure. So if you’re sure how long the recovery is going to be, you can just be honest. Don’t give people unrealistic expectations of Ah, they’ll probably be able to extubate ’em tomorrow and they’ll be fine. So I think realistic expectations about what the trajectory of the recovery will be like if I feel like I have a good idea of what someone’s recovery is going to look like, I’ll lay that out for them so that they know. And I won’t necessarily put dates on it, but I’ll say, first this has to happen, then this has to happen, then this will happen. And then they’ll be ready to go. And I think giving people those kind of milestones lets them know over the course of the next week where they’re at in the recovery process,
Speaker 1 (00:15:42):
What I like to do is kind of bring the patient into the whole process. And first I ask for their patients because I can’t predict the future. I can’t say that I know every single answer. And so be patient with me, we’ll figure this out. I’m here. And also kind of remind them that I’m not just going to leave. There are doctors that kind of like, I’m done with it, go to pain management or a hernia is fine, just go home. And the patient’s legit saying there’s something wrong with me still, and they feel like they’re being abandoned. So I never want the patient to feel abandoned in any way, but I’m a bit realistic. There may be situations where I don’t know the answer yet. It’s going to take time for whatever the problem to evolve, and so I can help figure it out. So I always ask for the patients,
Speaker 2 (00:16:37):
Correct? Yeah,
Speaker 1 (00:16:39):
It’s a process.
Speaker 2 (00:16:40):
And I think another thing too, and the other end of the patient’s coin is if you’re going to say for instance, okay, I know you’re having a little bit of pain after your inguinal hernia repair. It’s only been two weeks. Why don’t we see how it goes and why don’t I see you in this date? Just so they have something in their mind and you could tell them, Hey, listen, if you’re feeling better and it’s gradually going away by then you can cancel this point. But why don’t we just have something on the books just in case you’re not getting better? And it’s such a comfort to them. And even when people, let’s say watchful waiting type scenarios where someone has a Hernia, it’s not that symptomatic, they’re thinking of putting it off. They’re not really sure they want to have surgery, they have a bunch of comorbidities. Those are the patients who I’ll say, why don’t we make an appointment for just six months from now? It comes up and you don’t want to make it. I’ll go home early. Great. And if you want that way, you just have something, you’ll know that you have that appointment on the book and we can touch base again.
Speaker 1 (00:17:41):
I agree with you. Yeah, providing that follow up just to double triple check is good. Here’s a question. So we had David on Krpata, Dr. Krpata, who’s really kind of been heading most of the groin pain part of your clinic, but can I ask you a groin pain question?
Speaker 2 (00:18:04):
Yeah, sure. Okay.
Speaker 1 (00:18:05):
All this is a patient, patient question. Could you please address sexual dysfunction for men after mesh surgery? I’ve been having dis-ejaculation since a TEP inguinal hernia repair, so laparoscopic inguinal hernia repair technique with mesh that was performed seven months ago and it’s not getting better. I’ve never had this before. The urologist say they can help then that I’m a rare case. I was born with only one testicle, and that testicle is on the operated side with the hernia. Can these problems be resolved or is it considered permanent damage? Should I consider Mesh removal? I would like to get my sexuality back. Imagery doesn’t find much apart from a displaced spermatic cord, which is a finding actually, and high scar tissue inflammation around it, which also is a finding. I feel sexual problems from men in post-surgery are very seldom addressed despite many of us having these symptoms. That’s true. I actually had a patient advocate who’s male come on this show specifically saying, I feel like all these mesh issues are being addressed for women, and then the men are kind of left without much direction. So I have some comments about this, but what would you like to say about these
Speaker 2 (00:19:15):
Conversations? You said it’s been seven months? Seven
Speaker 1 (00:19:18):
Months post-op from a laptop.
Speaker 2 (00:19:20):
A laptop, okay. So I mean, again, this is not my particular area of expertise because we’re fortunate to have David Krpata who handled a lot of these complex cases. But I will say just in general, there are things that happen in the human body that sometimes we just don’t understand. And I think that if you put a foreign body inside of someone, and I’m someone who puts permanent material all the time, so this isn’t against permanent material. The vast people do get benefit, and that’s why we do it. There’s a risk benefit ratio, but there are things that happen in medicine that just people don’t understand. And the bottom line is if that mesh was put in and you’ve lost that type of function, that timing, of course you’re going to make that connection. And so I’ll just say this, if it were me or if you came to see me, I would say that once, I would probably give it more time.
Speaker 2 (00:20:22):
I might give it a full year just to see if it was something that went away on its own, but if it did not, then I would just offer to take the mesh out. And again, the caveat being, and I think just being at the clinic that we tend to do things just because oftentimes folks like yourself have been to many doctors and they feel like they’re at their wit’s end. They feel like no one’s listening to them. And so I think that someone has to be willing to do these types of things with the caveat that, Hey, listen, I will do this, but just understand. I can’t guarantee that the consequence is going to be that you’re going to get your sexual dysfunction back. I do things like that all the time where you do too treatment where it’s just like, I’m willing to do this just as long as we’re on the same page of I can’t guarantee that it’s going to help.
Speaker 1 (00:21:15):
Yeah, I would say what he’s saying is this patient’s saying is exactly right, which is there’s not enough. So the urologists don’t really understand what we do surgically. And so they’ll ultrasound the testicle and be like, oh, good BL flow, no epididymitis, you’re good. And then the hernia surgeons aren’t really understanding the urologic and sexual function part of it. So your general surgeon perhaps who did the angle Hernia repair may be like, you don’t have a hernia recurrence, we’re good. But what happens is, especially with laparoscopic surgery, I see in men, one of two things happens. Either there’s too much overlap of the Mesh with the spermatic cord, and so that can cause testicular pain and so on. Or what they sometimes do is the keyhole technique where they wrap the mesh around the spermatic cord, and that could be very, very painful if it starts eroding into the cord.
Speaker 1 (00:22:12):
And that erosion can cause erosion to the vast, which makes ejaculation very painful, for example. So this finding of a lot of scar tissue and displaced spermatic cord maybe because that keyhole technique was used and the only way to treat that is to remove the mesh, or B, the way that the hernia was repaired is now making the trajectory from your testicle to your prostate abnormal. So I’ve seen kinked cords, it kind of goes up and then it makes a little L before it gets because of the way the mesh was placed. In any case, technically speaking, the sexual function has not been altered because the nerves and all that are normal. It’s the scar tissue and the interaction with the mesh. So these findings on imaging are real. Those are not much findings. It’s actually quite a bit of finding already that someone’s been able to figure out, and usually you need the mesh and the spermatic cord separated to address it. The good news is testicular function should be fine, and the ejaculatory function should be fine. It’s just with pain plus this interaction with the mesh, you are distorting the anatomy to the point where you’re getting pain, and I’m not sure, well, I guess this ejaculation would be the right term. It’s just very painful because the vast may actually have an erosion or a kinking where the spermatic flow is disrupted. So it’s treatable. The good news is treatable. Okay. Next question.
Speaker 1 (00:23:57):
Is it common to have a sinus arrest for 30 to 45 seconds with carbon dioxide insufflation during laparoscopic surgery of the extra peritoneal area? And what are the reasons for that?
Speaker 2 (00:24:15):
So extra peritoneal dissections, I guess. Well, I guess technically A would so that those have been around a while. It has become a lot more common because with the robot, the extra peritoneal dissections have kind of gone up tremendously. And so we’re doing it for ventral hernias as well. That’s true.
Speaker 1 (00:24:34):
Yeah,
Speaker 2 (00:24:35):
I have not, and so the higher up you are, I think the more likely that insufflation in that plane will tend to creep into patient subcutaneous tissue and may have consequences like PCO2 increasing. I haven’t even heard of case report. I feel like that’s the kind of thing where it might be posted on IHC or something like that, and I have not heard of incidents like that,
Speaker 1 (00:25:03):
But there are situations where when the patient is, let’s say low volume, they fit fasting for surgery for a while, and then you, and then you quickly add pressure to the abdominal wall, right, that can drop your blood pressure, I guess
Speaker 2 (00:25:18):
Intraperitoneal. Yeah, because IVC collapse. Yeah, absolutely. But extra peritoneal, I have actually not heard of
Speaker 1 (00:25:25):
That. Not as common. Yeah, I agree. This says that Dr. Petro mentioned his infection rate. What is a timeline for an infectious complication to occur if you’re a patient who travels to have surgery? And this is a very good point. If you have a patient who travels to have surgery with an expert such as yourself, how long should you plan to stay at a hotel? So if the infection occurs, it can be addressed by the operating surgeon in the city of travel? Excellent
Speaker 2 (00:25:51):
Question. This is such a great question. And so this comes up all the time because folks travel from all over, and what I tell them is usually I will keep folks in the hospital maybe a little bit longer, especially if they’re traveling, it might give them an extra day or two in the hospital. Then when they leave, I kind of put it this way, depending on the time of year. So obviously if you have to worry about snow and getting to Cleveland, depending on
Speaker 1 (00:26:20):
What
Speaker 2 (00:26:20):
Snow, snow, depending on the time of year,
Speaker 1 (00:26:25):
If the sun shines a little bit too much.
Speaker 2 (00:26:27):
Yeah, exactly. Or not enough, and then how far they have to go. So folks that have a three or four hour drive to West Virginia, I might say, okay, listen, you can go back, but just understand if anything happens in the next week or two, you got to drive all the way back three or four hour drive. Usually I let them go home if they’re comfortable. The other thing you have to take into account is just what their means are. Can they afford to stay in a hotel or an Airbnb for a week or do they have family in town or something like that. If they have family in town, I’ll be like, just stay with your family for a week. That’d be great. I can you in the office maybe next week or 10 days later. And then after that, because usually you want to see someone about two and a half to three weeks, usually by three weeks.
Speaker 2 (00:27:12):
If the wound looks good, you’re probably fine. So the folks that are flying in, it’s usually, again, these are for bigger cases usually why they’re coming here for flying in. So it’s a week in the hospital, it’s why don’t you stay in town for two weeks and then if everything looks good two weeks after discharge, I feel comfortable with going the folks going on the back. Some people do leave before that and just understand, listen, that’s fine. If anything happens, you got to come back. Or if I happen to know someone in town where I can have ’em go see someone else locally.
Speaker 1 (00:27:49):
Yeah. The good news, we’re all very well connected, so we’re friends and we’ll help each other out, but I feel guilty if I operate on someone from a different state. Let’s say I operate on someone from Cleveland and then they go home, they have a wound complication, I’ll be like, Clayton, can you take care of my wound complication? I would do it. I would take advantage of that, but I would feel guilty. Right.
Speaker 2 (00:28:12):
Yeah, no, I don’t think, I mean I’ve had that happen. This actually, I just sent someone home this week to St. Louis, and I had sent an email to Jeff Blatnick and I was just saying, Hey, just so you know, I’m sending this patient back. She says she can’t afford to fly back. If anything happens, if anything happens, you’re on the hook.
Speaker 1 (00:28:32):
Yeah, yeah. It’s a problem. Problem. Here’s some more prevention of seromas. If as a patient you’re covered in Mesh, from groin to groin, IE, you have additional groin surgery, is there a requirement to insert a drain to prevent a seroma? Are there any situations where you would place a drain to prevent seroma for groin surgery? No matter how complex
Speaker 2 (00:28:59):
For groin, the only scenario I leave a drain for groin folks is if they have ascites because they have cirrhosis.
Speaker 1 (00:29:06):
True.
Speaker 2 (00:29:07):
That’s the only scenario where just, I mean you have everything working against you, particularly gravity, and that is, that’s the one scenario where, and to be totally honest, I don’t even know if it helps sometimes, but that’s the one scenario. I do leave a drain, otherwise I don’t routinely for inguinal hernias, even if it was bilateral, I don’t routinely leave drains.
Speaker 1 (00:29:32):
I’ll tell you the times when I do put drains, which is also rare would be if I’m shaving, mesh off bladder because can bleed and because closing the space, you don’t want blood to accumulate in a space where you just place mesh. It can lift the Mesh off of your repair. So that’s the only time that I do it. Bladder,
Speaker 2 (00:29:59):
I would say very, very large inguinal scrotal where you’re having to do an open s Stoppa type repair in the scrotum, I will just leave a drain.
Speaker 1 (00:30:11):
Yeah, that space is now empty. Whatever. It’s empty space. It’s at risk of filling up with fluid or blood. Another seroma question, treatment of chronic seromas. What is the standard treatment to treat chronic large seromas either of the abdominal wall or the groin? Do you allow the body to absorb the fluid or do you insert a drain to shorten the time period and discomfort? Good question. Yeah,
Speaker 2 (00:30:35):
It’s a great question and there’s a lot of nuance in that question too. So it sounds like the person is pretty experienced. So I’ll start with the ventral. So the ventral post-op seroma where the patient feels the bulge but it’s not infected, incision looks perfect and it doesn’t bother them. I will probably leave that alone. That is the most common scenario. And in those cases, again, you just want to leave it alone. If you’re lucky enough that fluid collection’s not infected, in most scenarios, the body’s just going to chew it up. If it becomes chronic and the fluid collection’s there and it bothers
Speaker 1 (00:31:15):
Like six months later,
Speaker 2 (00:31:16):
Like three to six months later, three months later, if it’s still there and it bothers them, then I’ll just open it up and I’ll cauterize the cavity and then usually make a drain close and eventually it will go away. Or sometimes just have IR put a drain in it, the
Speaker 1 (00:31:33):
Interventional radiologist
Speaker 2 (00:31:34):
If it’s chronic. But if it’s chronic, you’re probably going to want to take the capsule out if
Speaker 1 (00:31:37):
The capsule will just continue just producing fluid, keep,
Speaker 2 (00:31:42):
Exactly. So usually we’ll just do that open if it is, and it’s super painful, I think then in that scenario, I would drain it and I would probably have IR put a drain it. It probably hasn’t formed a capsule yet, particularly I tend to leave. You just go through
Speaker 1 (00:31:57):
The scan, the interventional radiologist,
Speaker 2 (00:31:59):
Yeah, I would’ve the radiologist scan because usually I take the hernia sac out so that capsule isn’t there, and so if the capsule hasn’t formed yet, I don’t feel like I have to open it up all the way unless it’s infected. So I would just have the radiologist put a drain, let it scar in, and then you’re probably fine. Honestly, even if it is infected, sometimes you can just do that and give the antibiotics and it’s fine as long as there’s no cellulitis in the groin. The groin ones are hard. The groin, the
Speaker 1 (00:32:29):
Scrotal skin, so elastic, it provides no external pressure like the abdominal wall. It could be tight.
Speaker 2 (00:32:38):
Fortunately, the groin seromas typically aren’t that painful. And so typically people will say, yeah, I feel a little bul here, but it’s different than the hernia and it doesn’t bother me. And thank God, because that’s a really common scenario, and I usually even will tell most patients with a sizable inguinal hernia when I fix the hernia. That is, like you said before, it’s just an empty space now, and the body fills empty spaces with fluid, so you might fill a bulge there. It’s fluid eventually, it’s going to gradually go down over the course of a month or two every once in a while. I mean, I can think of one or two times in the last five years where not only has it been there, but it’s been exquisitely painful. I don’t know what your experience is Shirin, but draining them in the office, they just seem to come back in your experience. And so I have actually once or twice just gone and made two small incisions and left either a vessel loop or a penrose to just let it drain. And usually I might do a week of prophylactic antibiotics just so the mesh doesn’t get infected, and that seems to work the best.
Speaker 1 (00:33:50):
The key is prevention in those. I have this whole wrapping technique where those big hernias that they get basically a jock strap with either lots of gauze or just take tube socks so that you’re just extra compressing. And then on top of that, they wear a compression underwear, like a base layer, like an athletic men’s underwear, and that tends to be a good prevention, but once you get the fluid, especially if there’s blood in it, that’s very heavy and there’s a lot of discomfort in it. Agreed. Okay. More questions. What lifestyle changes do you recommend to decrease inflammation systemically and reduce chronic pain associated with areas of hernia repair? Specific adhesions. Is there anything you do to reduce adhesions from your big abdominal bowel hernia?
Speaker 2 (00:34:40):
No, not
Speaker 1 (00:34:41):
Really. I mean, there are things you can put to reduce adhesions for the bowel,
Speaker 2 (00:34:49):
Like Sepra film or something.
Speaker 1 (00:34:51):
Sepra film and Interceed. Do you use intercede?
Speaker 2 (00:34:54):
I don’t you
Speaker 1 (00:34:55):
Should consider it. It’s basically sepra film, but it feels like surgicel. So it’s like a fabric so much easier to handle, especially laparoscopically.
Speaker 2 (00:35:05):
Yes. As you know, Sepro film ISS just a nightmare to handle.
Speaker 1 (00:35:08):
It is, but reed is not. It’s just like fabric. It’s like surgicel.
Speaker 2 (00:35:12):
I will say when I take down adhesions, I always mobilize the omentum completely because when I take the towel out, I always just want the omentum. I usually pull the towel out and then I take the bottom of the omentum and I put it in the pelvis. So that way the event is covering everything, which
Speaker 1 (00:35:29):
Is, that’ll be ideal,
Speaker 2 (00:35:30):
How God wanted it because you have your posterior sheath closure. a lot of the repairs we do, I know this is really kind of getting into the weeds, but we’re putting Mesh between layers of muscle so that the mesh isn’t for the vast majority of big cases, so the mesh isn’t rubbing up against the intestine, but you still have that layer of muscle, that thin layer that you’re covering the bowel with, and you’re saying that together. And so if anything’s going to stick anywhere, it’s going to stick to that layer that you were
Speaker 1 (00:35:59):
Manipulating. That’s true. Which is a good thing.
Speaker 2 (00:36:01):
So if you take the omentum and you cover the bowel, the omentum is just this big fatty veil that covers the intestine, and if you have that kind of covering your bowels like a little blanket, I call that God’s towel. So that way you have something and that way if anything wants to get stuck up to the layer that you were manipulating, it’s going to be the omentum and not the bowel.
Speaker 1 (00:36:28):
Yeah, I think there’s something I learned about tooth called icodextrin. I don’t know if you’ve heard of that. What’s the brand name of it? It’s also made by Baxter the same, I think. So icodextrin, it’s like a liquid. It’s like a IV bag that you just swish the bowel with before you close. That’s supposed to decrease adhesions too, but try, it’s actually marketed towards a gynecologist. So when GYN does all their endometriosis surgery or pelvic exoneration, they put that down and it works really well. I went back in a patient with stage four endometriosis and it was like as if no one was there. It was so beautiful. So I’ve become a big fan of it, but you have to go to the GYN side of Ethibond and ask for them because they don’t market it to general surgeons, even though it’s great. Let’s see. Is mesh best removed by implanting surgeon or a super specialist such as yourself? Good question.
Speaker 2 (00:37:36):
That’s a good question. You can usually gauge by your surgeons by how apprehensive they are to take it out, whether or not that’s the right person. That’s so true. If you’re a surgeon that you go back to and you’re like, Hey, I have a problem, I really need this Mesh out, and they’re like, I don’t really think we should do that, then that’s probably not the person who you should force to take mesh out.
Speaker 1 (00:38:03):
Yeah, don’t force them.
Speaker 2 (00:38:05):
Yeah, I mean, so again, getting into the weeds here, there’s so many types of different Mesh and so many different places to put it. So depending on what type of mesh you have in what part of the body, then it can be easier or harder to take out. And so if you take the Mesh out, I will say then there’s a pretty good chance, not so much for inguinal. I’m actually shocked by how often when you take inguinal Mesh out, people don’t get inguinal hernias back. I feel like that hasn’t been publicized enough.
Speaker 1 (00:38:37):
They eventually do, but yeah.
Speaker 2 (00:38:39):
Yeah. Well, maybe eventually, but it’s not as opposed to ventral where if you take a ventral piece of mesh out, it’s almost inevitable that you’re going to get a hernia. So I would say in the spirit of planning for the next Hernia repair, you should probably give the surgeon that is going to eventually do the next Hernia repair. You should probably give that surgeon the chance to take the mesh out so that they can decide what they want do, how they want to do it. They’re going to be thinking like, okay, I need to think of not just taking this mesh out, but I don’t want burn any bridges for next time. So I always like if I’m going to be taking someone’s mesh out and then also having to deal with the sequela of that, I’d rather have been the person that took it out the first time.
Speaker 1 (00:39:21):
That is such a good point. I mean, I never want to impose on the patient to force ’em to come back to me afterwards. There are reasons why they may or may not want to come back, but I really do want them to come back because I kind of have, like you said, plan A, plan B, plan C about what will happen and how I would address it based on what I’ve seen already in the measure renewal process. And that’s a good point. Do not force your doctor to do something that they don’t feel comfortable doing. Yeah. Question, which antibiotic does Dr. Petro use to prevent infections in the seromas he mentioned?
Speaker 2 (00:40:02):
Yeah, again, I don’t do that that often, but I would say for all those
Speaker 1 (00:40:06):
Seroma, all those seromas,
Speaker 2 (00:40:11):
And I’ll just say for cases that are not involving a stoma or something dirty, so clean cases, which is most inguinal, umbilical, ventral hernias for surgical site infections or things where I’m worried about, I see a little wound cellulitis and I don’t have a culture to go off of and I just want to send someone home on something. I usually do doxycycline because for a few reasons. One, it typically covers MRSA, particularly here on our antibiogram, it’s relatively safe. I mean, you figure there’s probably hundreds of thousands of teenagers taking doxycycline for acne across the country. And so that’s true. It’s pretty well tested. And I mean the biggest reaction that you can have to it is that photosensitivity. And in Cleveland, we don’t have to worry too much about that, but because of that, I’ll either do doxycycline sometimes I guess if they couldn’t do that, I might do Bactrim.
Speaker 2 (00:41:13):
Again, I think in today’s world, you almost have to assume that a good chunk of folks are going to have MRSA. So I tend to prefer to cover for that if I don’t have a culture, obviously, if I have a surgical site infection and I’ve cultured it, but a common scenario is someone their day, they’re ready to go home and their wound is just a little red, and I don’t have a culture. I don’t want to open up the incision and I’ll send someone on a week of doxycycline or Bactrim for wound cellulitis, and more often than not, my nurse practitioner will message me a week later and say, everything looks fine.
Speaker 1 (00:41:51):
Yeah. The underlying message is you really want to cover for the MRSA bacteria, at least in the initial, because that’s a bacteria you really should cover for, especially if they’ve been in the hospital before. So we talked a little bit about mesh complications, but this, it’s a pretty good one. As specialist, what suggestions or changes would you both suggest to help improve patient outcomes in the public sector? If you could change the scope of surgical practices, IE guidelines recommending tissue repair for small hernias and suitable patients. But the gold standard appears to be that general surgeons are implanting me in every patient who presents with a hernia, which in my opinion is one reason for an increase in complications. It’s kind of that whole tailored approach. Just because the study says that there are better outcomes, let’s say lower recurrence with match, does that mean every patient should have mesh? And how do you recommend that that should be diss to our population?
Speaker 2 (00:42:54):
I could probably talk for 10 minutes about this, but also just cut me off if I’m going for too long. So the full answer to that, so the reason that we use mesh for incisional hernia repair dates back to a study that was done in the Netherlands. It’s the Lyon Dike study. It was published in New England Journal of Medicine in the year 2000. It was for small incisional hernias, less than six centimeters, and they took patients and they randomized them to suture closure alone, or they had to put a little piece of mesh with only two centimeters of overlap, and they didn’t even necessarily close the fascia over top. And what they found with that was that the recurrence rates long-term were much lower if you use a piece of mesh to be true, if you actually look it up, the recurrence rate’s actually pretty high in both. Yes,
Speaker 1 (00:43:45):
It was pretty high.
Speaker 2 (00:43:46):
Statistically it was lower,
Speaker 1 (00:43:47):
But it was pretty high. Still
Speaker 2 (00:43:49):
Statistically high in it’s
Speaker 1 (00:43:50):
Like 40 versus 60% or something in that range.
Speaker 2 (00:43:53):
Correct. That data has been extrapolated to all ventral incisional hernias of all sizes. And that is, and the other funny thing is it actually hadn’t been repeated to this day. There were other trials that tried to get it started but never actually finished for a number of reasons. And so this is what we know. We know that based off the data available, it seems like, it seems like mesh does reduce recurrence rates. The best data that we have available in terms of mesh complications is by Kovic. It was published in JAMA and that they looked again at a large Dutch, and they found that the Mesh complication rate requiring reoperation is about 5% over the course of five years. And so we know that Mesh reduces recurrence rates, but it also has some degree of complication rates over the course of time. We also know that the technique that was used for that study doesn’t really replicate what modern techniques are.
Speaker 2 (00:44:57):
And so for instance, we know now that when you close the fascia with just suture, you should use small bites, small advancements, small needle. So the small bite four to one ratio or the length of the suture has to be so long so that you know didn’t travel too far. And your bites have to be close together. And the idea is that a lot of things that are really close, like the zipper is really strong, but it’s just a bunch of real tiny things. It’s stronger than a button shirt because the button’s really far away and you could probably just rip it apart. So that’s the idea. Good analogy.
Speaker 2 (00:45:30):
Again. And then for the overlap, they only did two centimeters of mesh overlap, which is again, not what we do now. Now we get tons of retro or preperitoneal overlap, and we closed the fascia on top. And so our opinion was that this study was way overdue to be replicated true. And so we’re in the middle of replicating it. And so we are doing for hernias that are less than six centimeters, these are belly hernias, ventral hernias, less than six centimeters, we’re redoing it and we’re randomizing patients in the operating room to either getting a small bite, four to one closure, and we’re also cutting the posterior sheath of the muscle because what we have found is that dramatically reduces the tension, the tension on the closure. And so if you cut the posterior rec sheath on both sides and you do the small bite suture technique, and then we’re comparing that to a modern, what we would consider a modern retrorectus technique where you put mesh in the retrorectus plane.
Speaker 2 (00:46:28):
And so we’re in the middle of that trial, and the primary outcome is not recurrence. The primary outcome is the patient’s quality of life at one year. Because again, I think that so often we get hung up on recurrence and what is a recurrence? If you had a hernia that was this big and you have a recurrence that’s this big, but it’s there on the CT scan, but your quality of life is 10 times better, does that really matter? And so it’s a very pragmatic trial and that we want to know, we really want to know from the patient’s perspective because our guess is that patients will accept some degree of recurrence to not have a piece of Mesh. And so we know that there’s a Mesh complication rate. We know that it’s real. And so we just want to be able to give patients the best chance to really get what they want, which is if you can get away without having a piece of mesh put in you and get the similar quality of life improvement, who wouldn’t want that? And so it’s actually a non-inferiority trial, and it is no Mesh, non-inferior to mesh in regards to the patient’s quality of life. So if you’re interested in no mesh repair, normally in the past, I would tell folks that you’re in the wrong place. But at the Cleveland Clinic right now, today, you’re going to be enrolling in our trial, we’re actually, we’re trying to make it a multi-centered effort. And so we’re in the middle of recruiting three or four sites, but we have to go through data use agreements and all that.
Speaker 1 (00:47:55):
That’s great. So I have two stories to share for you. Okay. One is the senior author for the paper that you mentioned. Y Yep. Came to visit us at USC as a visiting professor at the county when I was at USC. And back then it was okay to just bring someone into the surgery to operate. We got paperwork to operate. Yeah, we got paperwork done, but he didn’t have to get a license to do it. Right. So he was allowed to come in and he gave grand rounds and he met with the residents and we’re like, we found a patient for you. Why don’t you show us how to do your beautiful incisional hernia repair with mesh? It was this kind of moderately obese Hispanic lady who had a C-section incisional hernia.
Speaker 1 (00:48:48):
So he came into surgery and said, and closed the defect, and we all scrubbed in watching Ucle operating, and he is like, you know what? This looks good. We’re done. I said, wait, hold on, hold on. Literally your research is the landmark paper saying you must use mesh in an incisional hernia. This is fine. The kid’s coming. And I don’t know if he was just tired, and he is like, why the hell do you have me fly from the Netherlands and then have me operate? What the hell? Or if he truly was not practicing what he was preaching, which was that, no, and let me tell you, it is the county system. I don’t know what happened to that patient. I’m willing to bet that Hernia recurred because she had all the risk factors for a Hernia recurring, including I think it was six centimeters, and he just kind of put it together.
Speaker 1 (00:49:45):
It looked under attention to me, but he is like, no, it’s fine. So that’s number one. The second is I a hundred percent love that you’re doing this research project because we need to be a little bit more innovative in how we treat patients and understand that a six centimeter hernia is different than a one centimeter hernia, which is different than a 12 centimeter Hernia and why they got the Hernia and the quality of the repair, all that’s important, and the suture use. So being in Beverly Hills, I’m also very interested in figuring out alternative ways of treating incisional hernias because like you said, the gold standard is to use mesh for all incisional hernias. So you had a surgery, you had a hernia from that. That will fail if you just close it again, just like how they originally closed it. So what we are doing, of course, it’s a very limited population, but still it is a population, is people that are candidates for a tummy tuck. That means they have enough of a laxity of the abdominal wall to actually get a tummy tuck with the extra skin and everything else that comes with the tummy tuck. They will undergo primary pair of their incisional hernia, and the plication is treated as a permanent Onlay autologous biologic. So you have the primary repair, so you’re doing a primary repair,
Speaker 1 (00:51:15):
But the plication that is done is part of the tummy tuck, which is the extra second layer. Closure is a permanent Onlay biologic.
Speaker 2 (00:51:29):
You’re right. Honestly, someone came to see me probably it’s been in the last year, and they told me that someone told them that, and I just sat there. You
Speaker 1 (00:51:39):
Laugh at them.
Speaker 2 (00:51:41):
I didn’t laugh. What a
Speaker 1 (00:51:42):
Quack. Who said that?
Speaker 2 (00:51:44):
Wow. I thought, but I considered it. But to be honest, I had not heard anyone describe it. But you’re right. Why is that not an Onlay? Why would that not decrease the tension on the closure or offload the tension on, okay,
Speaker 1 (00:52:03):
It’s not for a 10 centimeter hernia. So we started small, right? We recruited patients and we started small. So one centimeter worked, two centimeter worked three, we went up to four centimeter. We’re now five years out with some of our patients. They worked last weekend I did an eight centimeter hernia, and the plastic screw was like, we can do this as a tummy tuck. And I said, no, eight centimeter. She’s had two incisional hernias before I take that back, because has had two laparotomies and both had incisional hernias and just closed it again. But she had a diastasis, multiple children, et cetera. Thin lady. I’m in Beverly Hills, remember my patient, popul is definitely different, at least the local ones. So thin lady, very fit, super lax abdominal wall because of all these surgeries and the whatever. So I said, I’ll have an open mind because we are in this learning phase. An eight centimeter sounds a bit wide to me. We took her to the or we put her under general anesthesia. And let me tell you, it was no longer eight centimeters. It was like five almost that came together so perfectly. Now I’ll follow her. Obviously she’s in our catchment group, but I think eight centimeter would be too much, but she really was in the or she was four and a half, almost five centimeters wide.
Speaker 1 (00:53:37):
And we’ll see how that goes. But this idea that every single patient needs a mesh, we’re starting to throw out.
Speaker 2 (00:53:45):
Yeah, I think we got to open our mind, like you said, and the implications, let’s say what we find is that our quality of life is no different. Well, then I could probably even spare the folks the laparotomy and do that robotically and again, cut the posterior sheath and just hole closed and spare. Now you could do the same thing with small incisions. So the downstream effect of if we start to realize what scenarios we can get away from using mesh, I think it definitely, I think like you said, we just have to open our mind to what else is possible.
Speaker 1 (00:54:23):
Yeah. Let’s get through some more of these live questions. I’m glad there’s so many. Let’s see. If a patient has cardiovascular disease stents, 60% blocked aorta and has developed several eventual hernias and a number of inguinal hernias, what precautions and disciplinary team would this patient require for the best possible outcome? I’m referring to my brother who now has a fear of mesh complications after witnessing my experiences.
Speaker 2 (00:54:49):
So I’m really lucky that I just have the best cardiologist in the world at the Cleveland Clinic, and I could just, yeah, you
Speaker 1 (00:54:55):
Really do.
Speaker 2 (00:54:56):
And all I need to say is, can I operate? And then once I operate, just make sure I do a good job. But if they say that they’re ready, and really it’s not even sometimes I think patients are waiting for someone to say, it’s not a yes or no, it’s a risk gratification. And so they just explain to them, you’re this risk, this risk or this risk, and then it’s optimizing and making sure there’s nothing else you can do ahead of time. So I am fortunate in that part. I’ll let the cardiologist dictate the risk question, and then I just make sure I do a good job in the or.
Speaker 1 (00:55:31):
True. Yeah, that’s true. I always say life four, hernia and patients that are higher risk, you don’t want the perfect Hernia repair. You just want the one that doesn’t kill them or improves their quality of life. And that’s where that study came from. The watchful waiting trial, not the watchful waiting trial. The weather hernias that are loss of domain and nine centimeters or greater should be repaired is they found a significant improvement in their quality of life. Even if it’s not a perfect hernia repair, they do so much better than having a huge nine centimeter hernia baby to walk around with.
Speaker 1 (00:56:14):
Let’s see. Thank you doctors for that valuable information. I am providing this information to relevant ministers. Oh, this person I believe is from Australia, along with requesting our government to be the first country to introduce an abdominal wall specialty or specialty as is being suggested by the American Hernia Society. Until that can be implemented, I am looking at changing the scope of surgical practices. Thank you again. So yeah, there’s some interest in pushing doctors surgeons to be actual specialized in hernia surgery, and of course that involves that whatever the society or board is to actually identify hernia as a specialty. What are your thoughts on that?
Speaker 2 (00:57:01):
So the fellowship council opened or invited a handful of places to make a fellowship spot with an official designation as a hernia fellowship. And I think they invited, I can’t remember, 5, 6, 7 places, but only two US and one other place ultimately did it. a lot of the places are kind of unaccredited, which is what we were, that mine was unaccredited outside any fellowship designation. And when you do something like that, it sounds great in theory, but it requires a lot of details to sort out in terms of what does it mean to be specialized in abdominal wall reconstruction? How many cases does that take? I know at our fellowship, it’s robot open, parastomal, tars, redo tars, managing chronic groin pain, Foregut paraesophageal is redo para. You
Speaker 1 (00:57:54):
Need that variety.
Speaker 2 (00:57:56):
And so it’s a lot, and not every place is going to be able to accommodate all of that. And so it’s hard. We’re sorting it out. We actually, coincidentally just interviewed our first batch of applicants yesterday, and we have one more round to go. So we are just getting started here. There are, I think, like I said, two programs followed through. And so there are two programs this year that are going to be ABWA fellowships officially with that designation with our fellowship council. And so hopefully,
Speaker 1 (00:58:25):
Who’s the second group?
Speaker 2 (00:58:27):
I think Penn State.
Speaker 2 (00:58:30):
But there’s other ones. They have it. They’re just not Abwa specific. Not accredit, ABWA and Bariatrics or some forgo or something like that. So there were only two that were kind of just focused on just abwa. And so there are other ones that are kind informal outside the match that are just through phone calls and things like that. But hopefully we want to be invested in the council. The reason we joined is because we want to be at the table when sorting out what numbers look like for what it means to be an AB wall specialist. And so hopefully we’ll move things along and so that other places can follow. Hopefully we will have more information on that in years to come.
Speaker 1 (00:59:14):
And do you expect people that train with you then to go out and develop their own Hernia program? Or are you hopeful that this will be an actual widely sought after general surgical specialty?
Speaker 2 (00:59:34):
We just want them to go out and just be good stewards of what we’ve taught them. And what’s really fun about this year is I’m pretty sure both our fellows this year we have two are going to be paired up with two of our previous fellows and they’re both considering taking a job. They’re like two or three years apart. And that’s going to be really fun because now with two surgeons, two of our former fellows working at the same spot in tandem, they can now have their own fellowship and so then we can be grandparents and we can just Yes.
Speaker 1 (01:00:06):
That’s so lovely.
Speaker 2 (01:00:07):
Yeah, I’m really excited. I hope it ends up that way. They’ve got really good opportunities.
Speaker 1 (01:00:12):
That’s really great. It’s so nice to see people that you’ve trained go out there and be the person you now refer to or that are training others and they kind of take a little bit of your philosophy over to wherever they go so the legacy continues. That’s really, really nice. One quick question before we leave. Do large rectus diastasis or large ventral hernias cause nausea or feeling sick to the gut during many types of physical therapy? Also, after a repair of such a large ventral Hernia, does a sickness and nausea issue usually go away?
Speaker 2 (01:00:48):
So I’ll withhold my bias and I’ll say that I don’t think that this studied well enough. I think that we have shown that we can fix diastasis in terms of the long-term follow-up and what the patient benefit is of that, I don’t feel like, and again I, I’m looking at it from a general surgery perspective and you probably have more of the plastics perspective on their types of outcomes in terms of what they can benefit. But I think that my perspective on this as a general surgeon not doing big abdominoplasties is there’s been a big push to plicate diastasis during hernia repair where there might be a small hernia within a diastasis and the patient wants the whole thing plicated. Or there are other techniques where you can go just on top of the muscle, the scola and you could just plicate. And so what I have found is that usually you are trading if they want it done for cosmesis, I often tell them, what I have found is that you are trading one cosmetic problem for another because if you don’t do the concomitant adominoplasty like you do Shirin the skin
Speaker 1 (01:01:56):
Part, yeah
Speaker 2 (01:01:57):
You’re just getting a tissue bulge and it just doesn’t look great. a lot of times it just flattens out with time anyway. For the folks that attribute the diastasis to other types of GI symptoms, my experience again has been that the two typically are not related. You can have a diastasis and GI problems and the two might not be associated. I will tell you that the textbooks would say that diastasis should be considered an asymptomatic type thing that is purely cosmetic and that can’t necessarily cause hernia type problems. Is that even your experience true or not necessarily? Pretty
Speaker 1 (01:02:39):
Much. Yeah. Pretty much. Yeah. But sometimes it’s not really a diastasis, it’s an incisional hernia.
Speaker 2 (01:02:45):
Correct.
Speaker 1 (01:02:46):
And it’s misinterpreted as a diastasis.
Speaker 2 (01:02:50):
Yep.
Speaker 1 (01:02:52):
Okay. Well thanks so much for your time Clay. I so appreciate it. It was really fun. Tons of questions. There are many that I wasn’t able to answer. I’m sorry. That’s okay. But we are running out of time so Alright, very good. I’m already very grateful because you are many hours ahead of me and so it’s getting dark where I am, so I appreciate it’s already dark where you are. It’s absolutely you’re with family. So thank you so much for your time and thank you everyone else for participating. Do watch this and share this episode with everyone. Follow me and subscribe to my YouTube channel at Hernia Doc and also don’t forget to write positive review on the podcast station, so that would really help the algorithm. Thanks everyone. See you all next week for another episode of Hernia Talk Live on Tuesday. Thank you.
Speaker 2 (01:03:42):
Bye
Speaker 1 (01:03:42):
Bye.
