Speaker 1 (00:00:00):
Welcome everyone. My name is Dr. Shirin Towfigh. Today is another episode of Hernia Talk Tuesdays. As you know, every week we gather together and get all your questions answered in a live format, anything that has to do with hernias. This is currently being simulcast on Facebook Live and as a Zoom and afterwards, I’ll make sure that you all have access to the videos to and share on YouTube. You can also follow me on Twitter and Instagram at hernia, where I will also post links to the YouTube channel. So today we have the lovely Dr. Michael Rosen. He is a hernia surgeon, the chief surgeon and most senior surgeon at Cleveland Clinic for their hernia center. Do you actually have a hernia center? I forgot to ask.
Speaker 2 (00:00:49):
Speaker 1 (00:00:51):
So Dr. Rosen, I’ve known forever. He’s past president of our American Hernia Society. He’s very well known amongst all of us throughout the world for hernias. He’s, I think, one of the tallest surgeons we have. So you always stand out from that aspect. You’re also, I’ll tell you guys, you’ll learn it in the next hour. His speech is very entertaining because he’ll just tell it like it is. And from what I understand, he’s super excited to interact with patients. He’s always had that aspect of him. And so thank you Dr. Rosen for joining me.
Speaker 2 (00:01:32):
Well, thank you very much. Like you said, I’m really excited to be here and I appreciate the opportunity.
Speaker 1 (00:01:38):
So we already have people logging in from as far away as Mexico City. We also do get people from Europe that come in. The timing’s a little bit off, but let’s get started, shall we? I’m going to go straight to questions.
Speaker 2 (00:01:54):
Speaker 1 (00:01:55):
All right. Let’s just start with some definition. What is a giant hernia, because that’s really the topic of interest for today, and what is your definition of loss of domain?
Speaker 2 (00:02:07):
So these are great questions. In fact, when I saw the title of this talk, I was a little bit like, huh, I wonder exactly what this entails. So I think probably the most honest answer to that question is so many things in hernia surgery, we don’t have great definitions and we don’t have standardization. And so those type of things really limit our ability to communicate on a higher level so that everybody really understands what we’re talking about. And I think that the struggles with that, a lot of us as surgeons try and use words that just are easy to understand and everybody can grasp to understand what we’re talking about. So I think if you step back and say, okay, well a hernia obviously just means there’s a hole and there’s something coming through there, right? Then what makes it giant? Well, I think there’s two big things to think about when we think about what is a giant hernia.
Speaker 2 (00:03:09):
I think number one is what are the challenges for the surgeon? And then number two would be what are the challenges for the patients, not only living with those hernias, but also overcoming the surgical procedures that are necessary to try and correct those. So I look at kind of giant hernias maybe as a broader term. Complicated hernias are things where the whole is very large, so patients tend to lose a lot of their core function of their abdominal wall. And typically the muscles that help you digest food, that help you take deep breaths that help you move your mouths, they’re gone. And so there’s a lot of quality of life issues that go along with not having that. And there’s a lot of technical challenges that come with trying to get all that stuff back together, get all the insides back inside and deal with all those things.
Speaker 2 (00:04:03):
So I think a giant hernia to me just means something really big that’s going to be a big physiologic strain for the patient. And then I think it’s also something that the surgeon, if they feel like it’s giant, they need to be prepared and make sure they have the skill set, the support staff, the right location to take care of all those. And I, I’d probably say the same thing for the loss of domain question. Just in general, when we think about domain, it basically just means you’re insides are meant to be inside your abdomen with all of your muscle and your core. They’re holding everything together. And when that breaks down, even if the hole’s not terribly big, if more of your insides, your intestines, your organs and whatnot, get through that hole outside the abdomen, when we push that back in, kind of loss of domain means you can’t anticipate pressure on your heart, pressure on your diaphragm. And I kind of describe it to patients. I think the easiest way to think about this is if you have a suitcase and you go on a trip and you’re there for 20 years and then you try and shove everything back in that suitcase, you’re going to be jumping on it, pounding on it, squeezing it. Yeah. And it’s not easy to get that to come back together. And that that’s kind of, I think for patients the easiest way to think about it.
Speaker 1 (00:05:28):
That’s a great analogy. I may steal that. That’s a great analogy.
Speaker 2 (00:05:31):
I’m sure I stole it from somebody too.
Speaker 1 (00:05:33):
I usually talk about clothing, but I think suitcase is a good one because trying to really, you could only expand your abdominal wall so much and you’re trying to fit all the intestines back in. At one point it was back in, right? Well, so why is it at one point it used to be all back in, but once you burst this abdominal wall that it, it’s hard to go back in again.
Speaker 2 (00:05:56):
Sure. So it’s kind of like when you think about a hernia, again, it, it’s kind of like if you have a hole in your tire every time you stand up, cough, increase your pressure inside your abdomen, take a deep breath, whatever, you’re pushing things out there. So every time that tire goes around, we know that tire, the balloon of it just keeps getting bigger and bigger and bigger and bigger. And while hernias don’t really pop, the pressure in that balloon just grows. Why some people get really big ones and others don’t, right? It’s not entirely clear why that is, but as it gets bigger and it goes out there, your body just is not used to having things back in that space. So it really does put a lot of strain on folks when we push it all back in there.
Speaker 1 (00:06:41):
In your practice, you do almost exclusively hernia surgery. You’re most well known for your giant hernia operations. I call ’em giant. Sometimes patients come to my office and they have a visible hernia and they say, oh, is this the biggest one you see? I’m like, no, bit bigger. I’m sure you get the same question. Is this the big as you’ve seen and you probably are not even close?
Speaker 2 (00:07:05):
My answer to that is thankfully for you, not in most cases. I think no doubt about it. I tell everybody, you definitely do not want to be special in my practice because typically those are very, very challenging cases for the surgeons, but also for the patients.
Speaker 1 (00:07:22):
Speaker 2 (00:07:23):
We get through all
Speaker 1 (00:07:24):
That. Yeah. The next question has to do with what it really involves. Let’s go to this next question. How is abdominal reconstruction different than a tummy tuck? What you do? How is that different from a tummy
Speaker 2 (00:07:36):
Tuck? That’s a great question. So I think when you think about abdominal reconstruction, you think about tummy tucks and kind of everything in between there, and you just kind of broaden it maybe to abdominal core surgery. If you just put it in that broad category, which all this stuff kind of fits in. W when we think about the abdomen and we think about surgery inside the abdomen, there’s basically, and when I talk to patients, there’s three parts that I need to be dealing with and they kind of come in equal levels of importance. So the first part is the intestines. And in any operation side, your admin, it’s really, really important that we deal with the intestinal side of it because there can be scar tissue where your bowels are stuck to different things and different hernias, and you want to make sure we don’t have any holes in those because those can create complications and leaks and whatnot.
Speaker 2 (00:08:24):
So that’s step number one. Then step number two is the muscle and the fascia that kind of give you your strength. And then step number three is the skin and kind of the subcutaneous tissue. So when we think about a hernia, there’s a real hole there, and so we have to deal with the intestines and then we have to do things to make those muscles that are no longer together come back together. And then we got to make sure we have good skin and soft tissue coverage. When you think about a tummy tuck, and most of the time I think when people are mentioning that they’re really meaning more of an abdominalplasty, but there’s also something kind of on other stream called a panniculectomy. And an abdominalplasty is commonly in people with a disease called rectus diastasis where there’s not actually a hole, but your six pack muscles that everybody has that kind of holds you together can be stretched out just a little bit commonly due to pregnancy, but other issues as well.
Speaker 2 (00:09:23):
And as that gets stretched out, you’re not really at risk for a piece of intestines getting stuck through there like the hole. But there are core issues that go along with that. There are back problems that go along with that. And for some folks they are symptomatic, and so often in that situation there is bringing that muscle and fascia back together. Typically in our practice, that’s often done with a plastic surgeon and often doesn’t require Mesh, but sometimes it does. And then the other part of a tummy tuck is that you remove a lot of the excess skin on the lower abdomen at the same time, so you kind of tighten back up the muscles and you remove some of the extra skin. And then there’s another obtuator called a panniculectomy in some of the more complex hernias where really there’s just what we call as a panis of extra skin, not necessarily with the diastasis, and we can remove that at the same time, but does add some morbidity to the operation. So all those things, we carefully decide what that is, but in every operation, there’s always the skin, the muscles, fascia, and then the intestines that we break up and how we approach those.
Speaker 1 (00:10:31):
One of the questions is about this excess skin. So do you routine when you have a hernia and it’s big enough that it’s constantly pushing out, it starts to thin out the skin. In fact, I tell my patients often the skincare is very important between now and when you eventually get your surgery because the skin can thin out, thin out, thin out, and then you can get complications that you get ulcerations or breakdown of the skin. So that I tell them to put some type of moisturizer on it, keep it moist, and then sometimes a binder helps reduce the pressure on the skin if applied correctly to reduce skin complications. But once they get to the point where you’re operating on them, do you routinely remove the excess skin or is that not necessarily a good thing?
Speaker 2 (00:11:21):
Well, so it’s really a case by case decision. It actually, when I was younger, we used to spend a lot more time at the same big hernia operation trying to make the skin look perfect. And what I’ve learned over time is that often when you do that, it requires extra incisions, extra dissection of the skin and predisposes you to potentially healing issues, blood supply issues, infections. And so what I really now try and convey to patients is that going to get rid of most of the extra skin with a limited resection, fix the hernia, and then a year later, once everything is all healed up, if there needs to be some revisions of just some extra skin here and there, that can be done at a much smaller operation and lower risk of those complications. So I, I’ve tended to not do them at the same time with few exceptions. And I think honestly, I think most patients really are more miserable from the lack of their core muscles and their hernia. Once they fix that, they feel better and they’re like, you know what? I’m good enough. Let me go. And then some patients are like, no, no, I really don’t like the way this looks, the scar, the whatnot. And then that can be done as a much less invasive revision of that scar tissue. And
Speaker 1 (00:12:43):
How much of that nasty or thinned out or new skin from the hernia repair does kind of regress and be look back nor normal or not so much?
Speaker 2 (00:12:53):
Well, I think if it’s really, so actually as we talk about those three layers, this is one of the most important things for the really what I like to describe as kind of the end stage of hernia repairs. And I think this is just to kind of touch on the second, because I think that there are a lot of patients who are told there’s nothing we can do for you. Yes. Because when you look at them, it appears that there’s not enough skin or soft tissue to be left behind once you get rid of all of the thinned out skin, the nasty skin and whatnot. And so this is where one of the things that we do offer, and I mean these are major 15 hour operations, but there are possible for the right patient where we actually do what’s called a flap where we take tissue, skin muscle and blood supply from the leg. And with our plastic surgeons, we’re able to actually do a flap where we actually can transfer that tissue and cover people’s abdominal walls, almost like a auto transplant of muscle and fascia. And so that’s really for kind of the extreme ca there. But when we have to resect and there’s not enough, when we know we’re going to take off the skin at the big operation and we know it, it’s not going to come back together. That’s where we sometimes do these things as combo cases.
Speaker 1 (00:14:07):
Does that include muscle and fascia or just fascia?
Speaker 2 (00:14:10):
Yep. Well, typically you can do perforator sparing. We, they’re called an anterior lateral thigh flap. And it basically just involves, if you think about your leg proximal, your femur, your thigh muscle, we can take basically the anterior compartment of that and there’s a big blood vessel that it comes on and we can actually plug it in the blood vessel inside the admin. And it really is, it’s a flat that it’s your whole anterior thigh. So it has a lot of skin and a lot of muscle. There’s some morbidity to the leg for doing it, but it really does cover things up and is again, a morbid operation, but can take patients who have been deemed no hope at all and give them a chance at a much better quality of life, perhaps not normal, but better.
Speaker 1 (00:15:00):
So we have a comment about how this is so amazing that you’re using your patient’s own tissue for as part of her repair and it should be the future. Do you want to comment on that? The morbidity is huge, and by morbidity I mean it completely changes your life in not a good way.
Speaker 2 (00:15:19):
Yeah, yeah. Well, so and maybe this ties into what do we need to put people back together? Yes. Whether that’s autologous tissue, whether that’s Mesh, what the Mesh is made from. Because these are common questions that we get, particularly nowadays when there’s all the things on TV and whatnot. And I think my answer to that for patients to understand is that nothing is perfect. I will usually say there’s no perfect surgeon despite how hard that is for us to admit. There’s no perfect operation, there’s no perfect patient, there’s no perfect Mesh. And all of these things have risks and benefits to them. And so something like synthetic Mesh does good, but in certain situations it can cause harm too. Like you said, taking autologous tissue, it sounds great, but always remember when we talk about a flap that is where we’re basically moving tissue from a donor site to a recipient site.
Speaker 2 (00:16:22):
By definition, the donor suffers some morbidity and the recipient is supposed to suffer or is supposed to get some advantage to that. And so for these big autologous slaps, we really use them as a last resort because as you mentioned, number one, they’re not quite as durable as a formal Mesh is. And we usually use them just for more of a coverage tissue coverage. And number two is, particularly for the big ones, while you’ll get that coverage in your abdominal wall, you will have some weakness of your leg that particularly for certain patients, can be life altering for sure. Yeah, no, you’re definitely, you’re in many ways of everything we do in surgery, you’re robbing Peter to pay Paul. And it’s kind of the art of finding that balance for how hard to push for the right patient and when to not push that hard and when to have those conversations. Because I think that particularly for more advanced reconstruction, no, nothing is perfect. And this is about getting the best quality of life while trying not to cause too much harm.
Speaker 1 (00:17:29):
But just to clarify that the risks of using, let’s say this thigh flap, right? One is that it won’t take, so once you’ve transferred over, it’ll die and you’ve lost it. The other risk is there’s a nerve, there are nerves there that you can damage. You’re permanently probably numb along that area. Like you mentioned. It may affect your ability to use that leg before it may provide weakness. And then also the abdomen is not flat after that. It’s a little bit, it’s rounded cause you’ve lost the nerves because it’s no longer a functional abdominal wall, it’s just a coverage. Right?
Speaker 2 (00:18:06):
Correct. And that’s really, really important to understand is that this is kind of for the end stage type disease or somebody who really thought, no way we’re going to be able to take care of this problem. But for the routine type hernias, even for some of the more complicated ones, as you pointed out, the morbidity of that is not worth the potential advantage of it being autologous tissue. Unfortunately, once you have a hernia, your autologous tissue isn’t where it should be. And that’s, that’s the problem For whatever reason, whether it was some technical issue with your operation, the way you heal, the quality of your fascia, bad luck, an infection you’re left with, your tissue is not back together. So now there will always be tension there, more tension than there was before. And that will always create this dilemma of what do we need to do to get it to stay together and heal for the second time in an area that’s kind of already proven that it doesn’t want to be together.
Speaker 1 (00:19:17):
So I’d like to just kind of keep on this topic because there’s a lot of concern that we are overusing mush. I agree that we are overusing mush. I think for example, a one centimeter belly, but hernia in most situations should not need Mesh. Although many surgeons do put Mesh in a one centimeter hernia. And however, for a 20 or 25 centimeter hernia, the width of my shoulders, if the hernia’s that big, the opportunity to do a tissue repair, that person’s already failed the fact that their tissue is just not healthy enough to withstand any operation. So they need some type of Mesh. And Mesh can be anything. Mesh can be a thick heavyweight polypropylene or it can be something like more biologic, less synthetic. We have a lot of technology that’s come about that is there’s not one type of match. There’s at least 30 in the market right now where you can choose.
Speaker 1 (00:20:20):
So this idea that all Mesh should be banned means every single patient that you do probably has no option or has a horrible option. I’ll give you an example. I had a patient who was in a horrible car accident, almost died, lost his spleen. His whole belly was filet open multiple times like compartments syndrome. So he came to me after, basically he was after he was alive, but he had all these fistulas and he had stool basically shit coming out of his belly. And his entire life was to wear gloves and just scoop out poop off of his belly. Long story short, I fixed him, but he had so much operations before that I had to do exactly what he said, the flap. So he didn’t have enough. He had lost muscle from all these Mesh. He had Mesh infections and the fistula. So he had lost so much tissue, I could only bring him back to this much and I couldn’t like a gap.
Speaker 1 (00:21:27):
And otherwise if you don’t close it, your intestinal will fall out. So we did a flap of muscle, which sounds interesting. You can use muscle from your butt or your side and bring it over or your leg and bring it over to a different place. But that muscle needs to be fed and it’s fed by the nerves. And if you cut the nerves because you just took it off of where it originated just a piece of it might as well be fat, there’s, there’s no function to it. And he got so depressed by the fact that he had used to have a flat belly. Now his true shit was coming out of it. Sorry, poop was stool was coming out of it, but it completely destroyed his life. The fact that he know had a round abdomen and people who make comments that are all inclusive Mesh should be banned, don’t understand that you could potentially make every single patient of yours be completely maimed if they don’t have the options of different types of meshes. You’re the specialist. You won’t figure out what the best Mesh is. But these giant hernias, they’re, they became like that for a reason. What are your thoughts?
Speaker 2 (00:22:43):
Yeah, interesting. Yeah. So listen, first of all, I agree with you. I think that the general statement of do we over utilize? Mesh is true. And I think that it’s probably important for everybody to understand how did we get here? Why do surgeons feel like they are using more Mesh? Well, it’s because when we didn’t use mass routinely, hernias failed. And so I think that and they came back. And so I think that from the surgeon’s perspective, we want to help people. We want to make the hole go away and we want to do the best thing we can. I think that, so I think we kind of go through a period, and this is how surgery works, is you, nobody does anything. Then everybody does everything and then you kind of wind up somewhere in the middle. And I think that that’s kind of what we’re learning now.
Speaker 2 (00:23:36):
And I think we have a lot more to go to figure this out. And I think everybody has to pitch in because as you said, the answer isn’t binary and it’s not simple. The answer, everybody should get Mesh and the answer isn’t, no one should get Mesh. Yes. So the only way to really figure this stuff out is for all the stakeholders to really engage in this process. And I think probably in 20 years in this field, what I feel like the most is a lot of people feel like a hernia is kind of like you get the operation you’re done for the rest of your life. You don’t have to think about that again. And I think one of the things that we’re learning over the years is not just for giant hernias, but for all hernia surgery is it’s a little bit more like orthopedics where when you get your back or you get your knee or you get your hip done, they tell you day one, this is going to last for 15 to 20 years and you’re going to need it done again.
Speaker 2 (00:24:34):
And so we all need to participate in furthering the knowledge. I think surgeons need to participate and put their data in registries and whatnot. I think industry, the makers of Mesh need to participate and follow these things carefully. And I also think patients need to engage in this and say, we really need to come back for follow up. We need to answer these questionnaires. We need to get this information out so that we can know what we’re doing and what we’re doing wrong. Because there’s no question in my life, the more follow up I have, the more people I see long term, the more humbled I am by thinking, wow, I’m not as great as I thought I was and we got to make this better. And that’s where true improvement I in this field comes from, is kind of looking at things and saying, what can we make it better?
Speaker 2 (00:25:24):
And if it’s improving patient optimization, if it’s improving surgical technique, if it’s finding the right Mesh. And the thing about Mesh, I think the hardest thing for people to understand about Mesh is, well, it’s very easy to point the finger where something goes wrong for the patient. I’m sure surgeons are guilty of this as well, is that when the Mesh goes in, there’s a lot of technique and skill in how that happens. And even in the best of hands, things can happen. There’s no question about it. But the way that all these things are done matter, and they probably matter to the outcome for that. So when things go wrong with the Mesh, we really need enough information to know how was it placed, what was the technique, what type of Mesh was it? And all those things so that we can get a large enough experience to then be like, okay, this is a real signal. We have a problem here and we all need to change. And a lot of things have to happen. I think for that environment to take hold. I think we’re getting some omentum. And I think actually just again, the fact that we’re here, we’re having this conversation, there’s patience there, there’s people listening. And the thousands of people who participate with you is so important because it just gets the message out there that, look, we don’t have all the answers and we all have to participate to get them.
Speaker 1 (00:26:49):
As scientists, we know that we don’t have all the answers, but it’s sometimes hard for people that are victims to accept the fact that we’re operating on people without having all the answers.
Speaker 2 (00:27:02):
Well, I think it’s so important for people to realize is that is at the end of the day, as a surgeon, you still have to come to work every day and you have to take care of patients. And in our world, there’s not always going to be enough evidence to be a hundred percent certain this is what we should be doing. And I think that level of honesty with patients is important to understand, Hey look, I am doing today, February 2nd, 2021, what I think is the best thing for you. And one of the things we do at the Cleveland Clinic, I mean we have 10 ongoing randomized control trials right now, and we really try about 70, 80% of the patients that we operate are involved in some clinical trial. And one of the things we talk to patients about is this is what we’re here to do.
Speaker 2 (00:27:52):
We’re trying to find the answers of what works and what doesn’t. And yeah, absolutely. Whether it’s technique, Mesh, whatever. And I think that that kind of passion to figure that out and then make a change. Cause I, I’ll give you one interesting. We just completed a paper and we just actually submitted it. Yeah. It looked at two different kind of meshes, like a heavier weight Mesh and a medium weight Mesh where people kind of felt like the heavyweight Mesh, you’re going to be able to feel it and it’s not good and it hurts for ventral hernia repair. And so the patients were blinded at one year later we asked the simple question, do you feel your Mesh yes or no? And amazingly enough there was 175 people in each arm and it was to the exact same number of patients with the two meshes said they thought they felt the Mesh. So I think it just shows there’s nothing perfect. And I think that we need to get the information we need to ask the patients and understand what they feel and what matters to them.
Speaker 1 (00:28:53):
What is your thought on biologic Mesh? Biologic Mesh, for those of you that are unfamiliar with a term, is basically Mesh, which is some type of product that’s used to bolster or bridge or help cover or a hernia. It’s biologic in that it’s not synthetic and they’re almost always, yeah, they’re always absorbable. So what are your thoughts on biologic Mesh and then cross-linked or not, especially in a pa, does it matter and especially in a patient who’s already had a prior Mesh infection, probably prolene Mesh infection.
Speaker 2 (00:29:30):
Yep, great question. So maybe I would, a couple maybe different perceptions on the biologic Mesh. So my biologic Mesh, what it basically means is that it starts from biologic tissue. So it could be pig skin, it could be cow pericardium there, there’s a whole bunch of different sheep stomach and whatnot that that’s where it starts from. But I always think it’s important for people to understand because it is a common thing to think. Okay. And the term biologic is certainly more accepting, especially nowadays than synthetic Mesh and the fear that goes around that. So I think one of the things I always like to tell patients is be careful about thinking something’s biologic because we are very good at taking biologic tissue and then making it synthetic. And the perfect example of that is actually if you terminally cross-link pig skin, so it starts off as biologic, then you make it into actually leather that we would all consider is something synthetic.
Speaker 2 (00:30:34):
So the idea that it’s biologic, so it’s safer, it is probably a stretch. You just need to be careful now, just like everything you said before, there could be advantages to making something more synthetic. It might make it a little bit more durable. So my general concept about biologic masks is I think in today’s world right now, I think that we don’t have enough information to know is it better than synthetic Mesh? Meaning better meaning less recurrences, less pain, less infectious issues. It certainly has been heavily marketed as that, but there are a couple randomized control trials. In fact, I’m one of the PIs, we’re actually, it’s about to be finished April 1st. It’s taken me eight years and we’ll submit it for publication. So we we’re about to analyze all the data where we put biologic mask versus a synthetic Mesh in kind of contaminated challenging cases.
Speaker 2 (00:31:35):
And we’ll see what happens at two years. Yeah, fascinating. No, I don’t think we know the answer to that. And I think that it’s a fair conversation to have with your surgeon. In my practice today, in today’s world, I don’t use a lot of biologic Mesh because I feel like if it’s okay to use a Mesh, I will use a synthetic Mesh. Otherwise I might not use a Mesh that day and come back another day. And then as far as costly can goes, like I said, I think there are theoretical advantages to it and then it might make it a little bit stronger, but there’s also some potential disadvantages that it makes it a little bit more synthetic. And so if you want something less synthetic and that’s why you chose it, you might not be getting those properties from it. But unfortunately, and I’ll kind of revert back and I think this is so key, this is where we really do need head-to-head trials where we can look at this stuff in kind of comparable patients say, is it really all just technique? I mean is all that matter that you have a good surgeon put it in that doesn’t really matter what your Mesh is or some Mesh is no matter what, going to cause harm and we need to take all that. And figuring all that stuff out requires time and engagement and investment.
Speaker 1 (00:32:46):
Yeah, everybody, yeah, we’re not born with all this knowledge. We have to learn from experience. I think those of us that used biologics in its early stages was one of them has either stopped or really, really red reduced how much biologics we use because the results are not there for it.
Speaker 2 (00:33:08):
But it is appealing. And I maybe I’ll just tag on it because that’s the other, the absorbable synthetics, so the newer ones out there. And I think in this world where there is a kind of overwhelming fear of synthetic Mesh for, and as we said for good reasons, in certain cases there’s a big push that, well, if you don’t want Mesh, why don’t you have this? And I would just stress, again, we don’t have a lot of understanding of these things. We don’t really know what happens long term and everything. There will potentially be some advantage to not having a permanent Mesh in there, but there might be some disadvantages in that hernias come back, they become more complicated. And I think we just need to kind of wait that out. Yes.
Speaker 2 (00:33:56):
My biggest message to patients is let’s whatever mess we choose here that that’s a little bit more like the golf club that drives the ball. It’s not really the club that’s making the ball go far. It’s the person swings the club. So a lot of that sure technique and you got to trust the absolutely the person doing it and no one Mesh is going to make it all okay for you. And it’s unlikely that any one Mesh is going to be horrible. And I tell most people, look, if you find a surgeon you like and they can do and they’re doing a good operation or experience, just do whatever they do best and if probably doesn’t matter what they put in, you’ll be okay. And if the mess isn’t put in, it probably doesn’t matter what the mess is made of.
Speaker 1 (00:34:45):
One of you mentioned synthetic absorbables. One of the questions is what is your opinion on pH t?
Speaker 2 (00:34:53):
Yep. So I don’t actually don’t have any clinical experience with that. So I can’t comment on my own personal experience. I’ve certainly had cases where I’ve operated where it’s been there before and whatnot. I’m a little bit more of a hard line. I don’t ever try a new Mesh unless it’s involved in a trial because I just
Speaker 1 (00:35:09):
Feel yes, I same. Yeah, I agree.
Speaker 2 (00:35:12):
I think that there are kind of concepts of it that I think are very appealing and I think the idea of how long do you really need the Mesh to be there is a fascinating question. But I think that the problem with all of this stuff is just hypothetical, right? And you know, need to do five year studies to say, okay, if I put this Mesh in, it might look okay at two years, but at five years it’s all coming back and people won’t be happy with that. So I think in today’s thing, I haven’t gotten in my practice, but I think that it certainly has some appealing characteristics, but I really think we need long-term data before we,
Speaker 1 (00:35:55):
Yeah, there are a lot of absorbable meshes and they’re typically absorb either within three or four weeks or around eight or nine months at least. That’s what the theory is. The synthetic absorbable phasix ST is marketed to absorb around two years, 18 months of two years. The thought being that that’s really all you need. And then your kind of tissue strength and scar tissue kicks in. We don’t have the five year data on that yet. And I believe the three year data is kind of iffy. I think it’s something, correct me if I’m wrong, like 20% recurrence.
Speaker 2 (00:36:31):
Yeah, it was pretty, it’s the biggest thing. My biggest theoretical concern with it is we know if we put a permanent synthetic Mesh in there, when you really follow these people out to five years, recurrence rates are higher than all of us wish they would be. So if a permanent Mesh is failing at 15%, 20% at five years, then one that goes away, it likely isn’t going to be better than that. Correct. Going to be the same or potentially worse. And the idea is just how much worse is it? And I mean, nobody knows the answer to that. If it’s the same, then I think, well if you don’t need something permanent, you all the better. But if it’s twice as high, then that might be a bridge to synthetic Mesh down the road, which isn’t necessarily probably worth another operation.
Speaker 1 (00:37:18):
You have another operation. So the operations you do are quite rigorous on you and also on the patient. The question is how often do you need your patient to go to the ICU or be left intubated after surgery?
Speaker 2 (00:37:33):
So we’ve actually done a lot of work around this because this is one of the big things is always to understand this and get the right resources available and plan it out. So the reality is it goes back to that first question, which is loss of domain. Yes. And can you predict once you push everything back in, how much that is? So we do some basic tests in the operating room. We somewhat eyeball it before surgery based on the CT scan in the exam and just kind of the general health of the patient. But I would say seven or eight years ago, I would probably say maybe 50% of my patients went to the ICU. I would probably tell you now, just because we’ve gotten probably better at selecting patients, better at optimizing, more efficient at doing the operation, I would probably say 10 to 15%.
Speaker 1 (00:38:21):
Okay. That’s great to know.
Speaker 2 (00:38:22):
Which is the most, is
Speaker 1 (00:38:25):
That because of you and your experience or now you have a team that’s more well-versed in recovery?
Speaker 2 (00:38:33):
I think, well a couple things. Think number one, I think it’s like everything when you kind of learn as you go. I think one of the things that I did learn over the years is when we were much more aggressive at keeping people intubated because you were afraid they weren’t going to be able to breathe and whatnot. And while that sounded like a great idea, there was a downside to that is particularly if you’re giving people paralyzing medicine and being in the ICU and the ventilator affects their lungs, that we weren’t necessarily helping as many people as we thought. Then we kind of refined it to predict what pressure we could take the breathing tube out and not go to the ICU. And so once we kind of figured that out, we were able to refine it and predict pretty well with that. And I think the other thing that’s just like everything, after you do a thousand operations of something, you get more efficient at it. It takes me much less time in the operating room. So they’re getting several liters less of fluid, it’s less anesthetic and we’re just more efficient at this operation than I used to be. And I think that helps as well. And I’m probably, the other thing is I’m probably good at knowing who’s not going to tolerate this operation and maybe say no to those people upfront or having them lose weight, quit smoking and all those type of things to improve your outcomes.
Speaker 1 (00:39:52):
We do have a question about weight loss coming up before that, a lot of really positive comments. Omg, music to my ears. I’m so impressed by two brilliant surgeons who are so scientifically rigorous.
Speaker 2 (00:40:04):
That might have been my mom, that might been
Speaker 1 (00:40:08):
Your mom says hi. Next questions about Botox. Do you use Botox for your patients? This is a technique that helps relax the muscles before surgery if to help close these big defects. If so, how many units and does insurance cover the cost?
Speaker 2 (00:40:26):
Yeah, great question. So I don’t use Botox. I did maybe 10 years ago and I kind of, one of those things we just talked about where I got better at the operation, better understanding how to do these things and close these patients. I have completely stopped using it. I know that it’s kind of a bit trendy right now to do it. Yeah, it’s very expensive and it’s a lot of expense that typically is born out on the patients because again, I don’t do this anymore. I know there’s some consideration of whether or not insurance covers it. I can tell you at my hospital, insurance would not cover it and the patients would have to pay for it. Yeah, it’s about $3,500 for just the Botox because it’s about 50 units. So I feel pretty strongly that it would really have to show that it’s better than my normal. And so I can just give you, we’re actually just submitting a paper with 1300 of these type of cases and we close about 95% of patients without any Botox. So you’re down to only 5% of people can’t be closed. Okay,
Speaker 1 (00:41:33):
Speaker 2 (00:41:34):
The problem is those 5% of people, the hernias are so big that Botox really isn’t going to help those people. So we’re actually, we’re just trying to get started. A placebo controlled double blind trial are we blind the surgeon, we blind the patients and we give a placebo or Botox to a certain group of patients who are high risk for not closing to see if in fact it adds something. Because this is one of those things that again, it makes intuitive sense, but it’s a lot of cost, it’s a lot of time. It’s extra visits for the patients. And so I really do think that we really ought to study this carefully before we just say, Hey, do it. And I guess my biggest concern about Botox is often I think that people who are less experienced with abdominal reconstruction might use it in an attempt to try and make the abdominal wall reconstruction easier and it’s not really going to change that. So you still on the day of surgery, you’re still going to be able to go there and put people back together. And so again, an area that needs to be studied, but I don’t do it anymore.
Speaker 1 (00:42:46):
Okay. One question about if someone’s already had nerve injury or a nerve severed from previous abdominal hernia repairs of the ventral hernia, is there any way to repair a recurrent hernia without Mesh and would a flap be something to consider?
Speaker 2 (00:43:03):
Yeah, flap. Probably not flap, just to kind of reiterate it, that really is the morbidity of that, unless we’re talking about just it’s the absolute massive hernia. We don’t typically go for flaps.
Speaker 1 (00:43:14):
Yeah, it’s very uncommon.
Speaker 2 (00:43:16):
And as far as the nerve and the Mesh and everything, that really does require sitting down on a case by case basis and understanding what happened in the first operation. Because the reality is a lot of nerve injuries are technical, not Mesh related, meaning that you got lost, you were in the wrong plane, or there was just a nerve you had to cut and there’s scar tissue around that nerve. So while the mess is kind of an innocent bystander, it’s not necessarily the issue and there’s no question that there are nerve injuries that occur. So kind of understanding that if it’s truly a nerve problem, then there are often things we can do to address the nerve. And then addressing the hernia is kind of a separate thing and once it’s a recurrent hernia, yeah, I’m hard pressed to say you wouldn’t need a piece of Mesh. Yes. There’s no question. Today’s world we get people who are just like, I mean I just absolutely don’t want it. And I would say, and I’m sure you’ve seen this in your practice as well, there are rare people that for just whatever reason that I don’t know why, just respond to Mesh differently than many other people for sure. And whether they get a incredible response, whether they get a lot of scar tissue or whether I have
Speaker 1 (00:44:34):
A fair number of patients with that, yeah, we presented at the meeting and we’re writing up our experience. Cause it’s a very unique but challenging set of patients
Speaker 2 (00:44:45):
And a fairness to a lot of people. I don’t think that number is incredibly high, super small. I think the people who have it are very devastated by it. And I think that what’s hard for us as surgeons and me in particular, and a lot of this more fits around the inguinal world, is you can have a Mesh that looks fine, but it’s causing pain and how to bring all that back together and kind of figure out what we’re doing. So I think when people, and just as when somebody, let’s say just make it easier when it’s a primary hernia, no prior Mesh or anything like that, and the primary complaint is pain that I think it’s important to step back as a surgeon and for the patients to understand that your pain might not be related to your hernia. It might be just related to damage that was done that gave you this hernia. And so fixing the hernia might not make that better and make sure you understand where the pain’s coming from at first because then otherwise you get in this terrible vicious cycle where essentially, you know, had somebody with pain and a hernia, now they have Mesh and pain and then trying to figure out where all this stuff started and how to fix it. It’s really challenging.
Speaker 1 (00:46:02):
We had at least one entire session on Asia syndrome or Schoenfeld syndrome, which the true systemic reaction to any implant Mesh among them. And it’s challenging and we’re working on figuring out how to at least either treat them or be able to predict we we’re not getting into anything very good yet. It’s very rare. And
Speaker 2 (00:46:27):
Yeah, I think the
Speaker 1 (00:46:28):
Hardest currently have are not good.
Speaker 2 (00:46:30):
I mean I think the hardest thing is identify those people even after they get it and then figure out what it’s going to take and what is a reasonable expectation of making folks better.
Speaker 1 (00:46:42):
What are the risks of sutures pulling out or the muscle tearing when suturing muscle? And can the risk be reduced by suturing technique or suture selection?
Speaker 2 (00:46:51):
So I would say anytime you have an operation when they close back up your muscles and you don’t have a hernia, but they just close you. Yeah, there’s great data that technique really matters. Oh yeah. Really for one of the very few things I would say is that we know that if a technique is done with, we call ’em small bites, very close together and it’s time consuming that improves outcomes. Yes. Now when we talk about
Speaker 1 (00:47:19):
Small bites technique,
Speaker 2 (00:47:20):
And that is kind of one of the few things in surgery where there really are great trials that kind of support that.
Speaker 1 (00:47:26):
So you use that regularly when you do your casual closure
Speaker 2 (00:47:30):
For not hernia patients when you’re fixing a hernia? I think So if you’re going to say, well let’s fix a hernia without Mesh and just use sutures, well we know that there’s a hole there, so there’s tension. And when you pull things back together, we do know that the sutures typically won’t hold together. Although I will tell you one of the next trials that we do want to do at the clinic, which I think would be a interesting trial that I don’t think has ever actually been done is for an incisional hernia, a smaller one, maybe five to seven centimeters or less, that actual small bite, four to one closure versus four to one closure with Mesh and see if potentially, as we kind of said before for the smaller hernias, maybe if you really suture it the right way, is that enough that that’s never actually been done? And I think that would be an interesting kind of Mesh versus no Mesh. Yeah. Type to see. But we don’t know the answer to that yet.
Speaker 1 (00:48:33):
So I have a unique population of women who want or are good candidates for tummy tuck and are willing to, I practice in Beverly Hills, I’m in what’s called the golden triangle. I believe there’s more plastic surgeons per square foot in my golden triangle than anywhere else in the world. I believe that’s a true fact. So tummy tucks are, a lot of people have tummy tucks. But what I’m learning is, cause I have a lot of patients of hernias and or need a tummy tuck. So we’re working on using the tummy tuck, the placation as your biologic to close the hernia. You close the hernia and then you then p placate the fascia on top of it.
Speaker 1 (00:49:22):
Obviously done with good technique. I have excellent plastic surgeons available to me and I work with ’em. And so we have a series of patients now that if they didn’t get the tummy tuck, I would’ve done a Mesh repair. incisional hernia. incisional hernia is by definition 50 or 60% recurrence if you don’t use Mesh. So Mesh is indicated, but I haven’t put Mesh in them. Instead they had the tummy tuck because it was within a diastasis or they had a previous tummy tuck that needed a revision. And knock on wood, it’s been I think last ones like four years and they’re doing really well.
Speaker 2 (00:50:03):
Well there’s no doubt about it. If you watch a plastic version close a tummy tuck, it’s usually two layers inverted. Yes. And they’re meticulous. So as we said, it’s, it’s not the club, it’s the person swinging the club. So I think that there’s no question about it that not people typically get in tummy tucks tend to maybe be younger, a little healthier and whatnot. But there’s no question that yes, correct. For some of the smaller things. It does make me wonder now for the really big things and I think that’s important.
Speaker 1 (00:50:37):
No, no, no, it won’t.
Speaker 2 (00:50:38):
You look, when you had two or three or four failed hernia operations and the hernia is really big at that point, we don’t have any other options. You’re going to need a big operation with a big, and it’s likely you’re going to feel better after that. Yes. But at the earlier stage, and I kind of liken it to, I feel like I want to tell people, Hey, look, and same thing, I think we talked about this for umbilical hernias. If you have a one centimeter umbilical hernia, I tell everybody, let me just stitch it up, there’s probably a 90% chance you’ll never need Mesh. And if you don’t need Mesh, you don’t want Mesh. And then if it comes back, then we can go ahead and put a piece of Mesh. So I think correct, perfectly fine. It avoids a lot of the stress and the concern and of what’s happened with Mesh, particularly in young people. So I think that for the small umbilicals, you should just stitch ’em up and see what happens.
Speaker 1 (00:51:31):
Correct. And I exactly. Part of that consent in agreeing to a non Mesh repair is then if it fails right, then there must be a discussion where you’re going to need Mesh. Obviously not in patients that are reacting too much, but these are the, and the typical patient, I’d love to know your behind the scenes preparation in repairing hernias of this great magnitude. You mentioned some of them can be 15 hour operations. I think typically they’re more than three or four hours of these really long operations. What is a tool on you as a surgeon before and after? And then also what rigors do you put the patient through before they’re eligible to have such an operation?
Speaker 2 (00:52:18):
Sure, sure. So for me, I’ve got to sort back and I’ve got to sore shoulder, there’s no question about it. I think one of the interesting things about this operation, particularly when you do it open, is that there is no, what we call a retractor, whether it’s kind of something that normally we put something in that kind of holds everything open in this operation. It’s really just you as the surgeon that kind of has to get exposure to do this. And that’s actually probably one of the biggest reasons that we do require weight loss before this operation. Because if you’re too heavy, we just can’t move things out of the way to see what we need to. And it’s just too difficult on our back. Now, knock on wood, I have not had back or shoulder surgery yet, but I sense that I will be there one day soon for that.
Speaker 2 (00:53:02):
But there’s no doubt about it, it does take a strain. I think it also, truthfully, these are big operations on people who often have a lot of other illnesses and whatnot. And certainly there’s a mental strain of just worrying about patients and making sure they’re doing okay. And so I think that’s kind of my segue into, it’s a lot for me. And these are long cases, a lot of stress and effort and whatnot. So I do want to make sure that the patients understand what they’re signing up for. And probably the biggest thing that I focus on is trying to have people understand that we are a team during this and the teamwork starts the minute I meet you. And so your role as a patient on that team starts getting ready before surgery. And that’s making sure that you’ve lost enough weight so that it’s safe and there’s no magic number, but it’s just doing the best that you can.
Speaker 2 (00:53:57):
Trying to quit smoking if at all possible, making sure that your diabetes is under control and really taking good general health, trying to walk and get your heart and lungs going to undergo that. And so you put that effort up front and then once you go to sleep, it’s on me. And that’s for me to do my job and bring all that. And I tell everybody, I’m like, listen, if it takes me 10 hours to put you back together, I’m not going anywhere. I’ll be there with you. Yeah. If I’m tired, if I don’t like my nurse that day, if I got in a fight with someone, if I got to get to my kid’s basketball game, I will be there until the end. So my expectation is no excuses from anybody. We’re all in this together. We’re all going to do our best. And that goes for post-op as well.
Speaker 2 (00:54:39):
So I think a lot of this is making sure that I tell patients also like, look, when you leave here, you’re going to get your surgery day, put that on your refrigerator and that is your day to get your life back together. So you train for that day and when I’m there I will. That’s how I see this is I’m here to make you better. Yeah, you got to see it too. And you can’t just be, put your arms out, say, Hey, I’m at the Cleveland Clinic Micros and take care of me because that that’ll never work and it, it’s got to be a team.
Speaker 1 (00:55:10):
And on that note, what do you do in terms of weight loss recommendations? One patient said their doctor told them they have to lose 30 pounds before they can have their hernia repair. Is that something that, how aggressively do you get involved? Do they do medical weight loss, surgical weight loss? So how much weight do they have to lose? And in patients that have such huge that are disabled from their hernia, how do you get them to lose weight?
Speaker 2 (00:55:36):
Yeah, so obviously obesity and being overweight is a very difficult disease and I think that we’re learning, yeah, there’s no easy fix for that. Bariatric surgery hasn’t been all fix. Medical weight loss isn’t an all fix. I think that this is a really, really tough problem to deal with that I have fought for most of my adult life as a surgeon. And so I think to answer the question, I don’t think there’s a magic number, but we have looked at this a lot, particularly at our quality Collaborative, and the bottom line is we look at what’s called your B M I, which is your height and your weight, and gives us kind of a general number and we want it to be about in the mid thirties, which is about where we think things are safe. Again, it depends on where you start. If you start at 50, it’s unlikely you’re going to get down in the mid thirties. So we want to see effort. And so what we have done, we have a whole program. We actually have a virtual coach that you get. Okay. Interestingly, 75% of people don’t actually call that virtual coach back just because there’s a lot of issues that go, oh
Speaker 1 (00:56:41):
My god. Yeah.
Speaker 2 (00:56:43):
We have a great bariatric program where we’ll offer people to get bariatric surgery if it’s possible to do a sleeve before this, which also can be difficult and not doable. Now, we typically recommend we have a whole medical weight loss program, which is a protein sparing fast. But ultimately, I think that, and I’d just like to stress this for patients, is this is your chance. And one of the things that, so most people who come to see me have had complications. A lot of them revolve around infection, and they often think of them more as rejection, but it’s really an infection. And the best way to reduce your chances of infection is losing weight. And so I want them to understand that, hey, look, I’m going to do a lot of different techniques in the operating room and try and reduce infection, but what I need you to do is get ready before surgery.
Speaker 2 (00:57:30):
So sometimes it’s 30 pounds, sometimes it’s 50, sometimes it’s 10. A lot of times it’s just kind of understanding mentally as a patient that, Hey, I’m about to potentially have a life altering operation. This is not, go to the hospital, go home, and I’ll never think about this again. You might think about this for the rest of your life every day if this doesn’t go well. So get yourself ready to go on that trip as best you can. And that’s kind of embracing, Hey, I have a disease. I got to do what I can to get ready. And so we offer support. True. It’s not perfect and everybody doesn’t lose weight, but we certainly try and do it.
Speaker 1 (00:58:07):
So true. So a lot of people thanking you. This is a very inspiring talk for them. We have one regular on hernia talk who I love, and she said she’s looking forward to contributing as the patient perspective on the ACH AHSQC Welcome Advisory Committee. So thank you Dr. Rosen for starting the Quality Collaborative, do you want to end with that? Sure. And tell us a little bit about it and what patients can do.
Speaker 2 (00:58:34):
Absolutely. So I, I’m the medical director and the co-founder with Bed Polisher, I think has also been on this before as well.
Speaker 1 (00:58:40):
He’s been on our show. Yes. Yeah.
Speaker 2 (00:58:43):
So basically we started this about eight years ago now. And it’s basically a way to try and bring all of the stakeholders together. And that is the FDA industry, surgeons and patients all to get together and try and understand what do we really need to do to improve outcomes f from a good place. And so I think patients are critical. And I think we have a whole patient advocacy committee, which I, I’m excited to be a part of. And I think that Harriet Schwartzman is the lead on that. And I think that we’re having our upcoming summit meeting in March where there will patients who are there to talk and interact with us. Cause I think that perspective is key. And everything in life, when there isn’t communication, there builds mistrust and people don’t understand what the other people are doing. And even though everybody might be trying to do something for the right reason to improve outcomes, if people aren’t communicating, the vision is not aligned. So we collect data, we reach out to patients, we’re trying to engage and try and figure out, quite frankly, what we’re doing and what we’re doing wrong and learn from each other. So obviously that’s one of my passions. And it’s certainly been a great eight years. And I’m glad that we’re finally kind of bringing in the patient perspective. And I think this is our next big leap forward, is to kind of leverage that relationship to understand what’s going on.
Speaker 1 (01:00:07):
And I tell patients, I encourage patients to not only find surgeons that are members of this quality Collaborative, it’s ACH AHSQC dot org. So surgeons like me who have chosen to be involved, every single patient we operate on that is formula related, gets plugged into this. And that means that I care about what happens to my patient years down the road. I’d like to learn more about my own patients and also others. So I highly encourage that either you find surgeons to take care of you that already have that commitment, or if you have a local surgeon who doesn’t, please tell them to go and become a member. I think it’s
Speaker 2 (01:00:47):
Speaker 1 (01:00:48):
It free? Yeah, it’s free.
Speaker 2 (01:00:49):
Totally free. In fact. In fact, I would echo the one thing I would just say is to me, what one of the things about the quality Collaborative I think is important, particularly for patients’ perspective, and I think it’s important to kind of put this out there, just like sports, athletics, everything. There really are, there’s going to be a spectrum of surgeons a across surgery. And so one of our goals at the Collaborative is not necessary to say we’re all going to be the same and have the same outcomes. But what our real goal is to say that we want to make sure that every single surgeon is the best possible surgeon that he or she can be by going through this process, looking at your outcomes, looking at your data, making sure you’re doing things. And so to me, what it really is, is stamp of is you have a surgeon that after every one of your operations, they’re going to sit down for two to three minutes and they’re going to say what happened?
Speaker 2 (01:01:49):
And they’re going to engage long term. And so to me, it’s almost like the better Business Bureau stamp, what you go in, you say, and so I tell all patients say, look, when you meet with a surgeon for an operation that’s going to have a device that’s put in you for the rest of your life, yeah. You want to make sure that that surgeon is invested in what’s going to happen to you for the rest of your life. So I think that’s really key. And I think for patients, that’s certainly something to ask and say, Hey, if you’re not, then what are you doing? Track your outcomes and why are you not doing that?
Speaker 1 (01:02:21):
Yes, absolutely. And it’s the only outcomes database that is focused on hernias. It asks so many specific questions, what suture did you use? What message did you use? What size did you use tax? What kind of tax? These are all so key because there’s so much chatter and concern and negative information about what we do as hernia surgeons because there’s so many patients have been hurt. There’s a lot of them. It’s not like hundreds or thousands. It’s more than that. And so this is the only manner that I know of that can at least prospectively kind of track what we do and then look at the outcomes to learn. Because I personally will have, I don’t know, five patients with a certain problem. But if there’s a hundred of me out there, we now have a database of 500 and we can learn much more about that. So thank you for doing that. Dr. Poulose was on this several months ago. It was really great because we also talked about his core health. And one of the resources on the ach AHSQC dot org is this patient and I give it to the handout to my patients on exercises they can do before, during, and after surgery from hernias. So,
Speaker 2 (01:03:39):
Well, there’s actually just, I’ll plug this out there too. Yeah. But anybody’s interested, particularly if anybody kind of has any abdominal oil issues or whatnot. Yeah. We actually have a free app. It’s on the iPhone or the Android. It’s ACH AHSQC, and it actually has physical therapy directed with pictures and videos of kind of how to rebuild your core after surgery and whatnot.
Speaker 1 (01:04:01):
Yeah, I’ll put the link on this on Facebook. Yep. Yeah. All right. What a great way to end the evening. Thank you for your time, Dr. Rosen. This ends us for our yet another hernia talk. We’re reaching our one year anniversary pretty soon because we started this at the beginning of the pandemic. Thanks everyone who follows me on Facebook at Dr. Towfigh, as well as on Instagram and Twitter at Hernia doc tonight. I will make sure that you all get the links to watch this and share it with your friends on YouTube, on my YouTube channel. And I will see you next week with yet another great guest. Very excited to share it all with you, and thank you for your time. I do appreciate it. Hope to see you soon.
Speaker 2 (01:04:46):
All right. Thanks everybody. Be safe. Bye. Thanks for having me.