Speaker 1 (00:00:00):
Welcome to Hernia Talk Live. We are here with you every Tuesday for our session on Q&As with our experts and friends in the hernia world. My name is Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Thank you to everyone who’s joining us on Facebook Live at Dr. Towfigh and on Zoom. And many of you also follow me on Twitter and Instagram at Hernia doc. At the end of this show, we will post, I will post the link so you can watch and share on my YouTube channel. I’m super excited because we have a true hernia surgery expert today. Not that anyone else was fake before, but we have Dr. Todd Heniford. Many of even of you already know him, know his name, you’ve read his articles. Dr. Heniford is a big deal. He’s at Atrium Health at Charlotte, North Carolina. You can follow him on Facebook at Todd dot Heniford and on Twitter at THeniford. So please welcome my friend, Dr. Heniford or Todd. How are you?
Speaker 2 (00:01:01):
I’m doing great. Thanks so much for having me, Shirin.
Speaker 1 (00:01:04):
Thank you so much for coming. I just finished surgery and ran to do this, but you always look dapper, so that’s good.
Speaker 2 (00:01:11):
Thank you. Yeah,
Speaker 1 (00:01:13):
So many of you know, and I already told you that as part of the kind of promotion of Hernia Talk, we seek questions from our people out there that watch and support hernia talk, and everyone’s really excited. So we have lots of questions for you, but I just wanted to kind of give you a little bit of intro, which is I first met you through the American Hernia Society, right? Meeting. You’ve been past present of the American Hernia Society meeting, and what’s unique about you besides, we all do hernia surgeries. We all put in Mesh takeout, Mesh, do tissue repairs, reconstructions, et cetera, because that’s our specialty. But what’s unique with you is number one, and you can correct me if I’m wrong, but I believe you may be the first or at least the largest kind of attempt initiation of a true hernia center where you have a dedicated space with surgeons and accessories to surgeons, whether they’re physical therapists, whoever, and lots of huge research team only dedicated to hernias.
Speaker 1 (00:02:22):
And you may recall in 2008 when I started at Cedar Center, I’d give you a call because I wanted to build a hernia center at my hospital, which didn’t work out. No one was interested except me. But as part of that, you did host me at your center and I got to see the whole area and how the flow is and your research and your clinical trials and the office flow. And it was really, really great. But maybe initially you can just tell me a bit about how it all happened. How’d you go from finishing general surgery residency to I want to a hernia surgeon to let’s actually make this a legitimate specialty where we have a whole center focus on one disease.
Speaker 2 (00:03:08):
Well, so no one starts wanting to be a hernia surgeon.
Speaker 1 (00:03:11):
That’s me neither. I’m Yeah,
Speaker 2 (00:03:13):
Of course, of
Speaker 1 (00:03:13):
Course. So true.
Speaker 2 (00:03:15):
And so after I finish my residency, I went to the Cleveland Clinic. And so I did really the chest and the abdomen and its content. I did lots of different surgery. And so I came to Charlotte. I was the first person really to start elective surgery. And so I did, oh, advanced laparoscopy, I did gastric bypass. We had the largest series in the world of distal pancreatectomy, gastrectomies, splenectomy all done laparoscopic fetal chromocytomas, huge series of this. But then you hire other specialists. And so where my real drive was, I do esophageal surgery. So I do hiatal hernias and I do a lot of, a lot of abdominal reconstruction, much like you. And so that’s where I spend a lot of my practice. So you hire a [inaudible], you hire bariatric, you hire my partner, Ken Kercher does all the south organ.
Speaker 2 (00:04:08):
We developed a real interest in doing abdominal reconstruction. Cause honestly, there was no specialist. The hernia repairs were actually done to get to the next operation. And so there was so much lacking as far as the science and hernia repair and real specialist and hernia repair. And you saw it, it in your place when I saw it at my place. We built our hernia center in 2004. You were trying to get people’s interest in 2004, you rang the bell. I was just very lucky to get our c e O of our hospital system and saw the real need. And then we were able to, so we now have three full-time data collectors who collect all of our data and has been doing that. We have over 10,000 hernia repairs at our institution that we’ve been able to track the data in. And this made us, it’s demonstrated for us how we can be better surgeons. And so with that, it’s interesting. I’ve had many fellows who’ve actually come in who’ve trained with us, and they come to do our minimal invasive surgery. They come to do the esophageal surgery. They come to do those sorts of things. And many of your very good friends, Mike Rosen in Naski and Igor Belyansky and Christie Harold, these people, they then go to academic institutions and they become abdominal reconstruction and hernia surgeons. And the reason being is this, cause no one who’s there who can do it.
Speaker 2 (00:05:28):
So they become pigeonholed into this area and they love it. And they become internationally renowned abdominal reconstruction surgeons. Because much, you feel this huge niche in California that whether it’s repairing your hernia or redoing your hernia or taking out the Mesh or taking care of complications or taking care of quality of life and those sorts of things. And then you become very busy. So our young people who come in with us try to and do invasive surgery, it’s so interesting how they actually go out and become and do what you and I do.
Speaker 1 (00:06:04):
And I think the other point I want to bring up, which is a nice segue, is because of what you started and probably your own personal kind of the way that you do work is you’ve mentored so many leaders in hernia surgery, so many future presence of the American, her society, people that have really pioneered different aspects of hernia surgery. And they’ve all kind of somehow gone through you, many of them. And that’s been really something very beautiful to see.
Speaker 2 (00:06:36):
Well, they would’ve been successful no matter. They’re super smart people. Yeah. I mean, driving personal excellence, they would’ve been successful if they were selling cars or whatever they did. They would’ve done extremely well. And they just so happened to land with me. And then they’ve gone on to do great things. And the wonderful thing is now the people that they’re training.
Speaker 1 (00:06:55):
Speaker 2 (00:06:56):
Yeah. I’m getting older, so I’m like, you know, had grand fellows. Yes. Which is not only fellows, the people that teacher you trained, but then the people they train, which is wonderful.
Speaker 1 (00:07:05):
It’s just, it’s really beautiful to see. And then it’s become a nice family. So it really
Speaker 2 (00:07:09):
Speaker 1 (00:07:10):
Speaker 2 (00:07:11):
It’s, and it’s interesting to see that you and I met when you were on, we were on board of the
Speaker 1 (00:07:17):
Speaker 2 (00:07:19):
When we were young and then
Speaker 1 (00:07:22):
I was younger, but yeah.
Speaker 2 (00:07:25):
But then they recruit you to come back.
Speaker 1 (00:07:27):
Speaker 2 (00:07:28):
So you would come back onto the board again because of, cause what you’ve leading and what you’re doing.
Speaker 1 (00:07:34):
Yeah. Yeah. Well, yeah, it’s become a passion for sure. And I think you also see this, I now have residents and others that now do want to do hernia surgery.
Speaker 2 (00:07:45):
Speaker 1 (00:07:45):
You’re actually enjoy it. They want, that’s their goal in life. Now.
Speaker 2 (00:07:48):
Your young people in the presentations they’re doing with this, the groin, the groin pain patients and the things that you’re doing robotically and the crazy cases that you’re taking on. And then your young, see what’s cool is now your young people are getting super excited and you’re training them to do this, and they’re going to pick up the mantle and they’ll go to Seattle or they’ll go to Michigan or they’ll go to Minnesota and your expertise will then spread to other areas in the country. Yeah. It’s very
Speaker 1 (00:08:19):
Congratulations. Very lovely to see. Yeah, it’s very lovely to see. But so on that note, since we both kind of aged ourselves already, I would like your insight because a lot of what we talk about is about hernia repairs, both ventral and inguinal. And our audience is super, super savvy, show you the questions that they’ve submitted. It’s pretty amazing. But let’s kick it off because the title of this session really is the pros and cons of Mesh versus Tissue repairs, which is, you’ve seen the history, right? Yeah. You’ve seen how Mesh repair kind of peaked, everything was Mesh repair. And now where I feel like we’re pulling back a little bit and seeing the pros and cons of Mesh repair, but then we also now have to relive what had happened. Why we started Mesh was because there was a lot of issues with tissue repair. So maybe you can give us a little bit of how do you see the world right now in understanding the history, which a lot of people don’t really understand, to give some clarity as to where we are now with meshes and non meshes and good stuff, bad stuff.
Speaker 2 (00:09:34):
And again, I think you just dated me again, but I’ll go with it. So when I was a surgical resident, we rarely used Mesh, the groin, and we did tissue repairs. And so I learned how to do tissue repairs. I think that where we need to base ourselves as far as taking care patients and as far as our practice goes, is in science. And so it’s not about hubris and it’s not about attracting patients and it’s not about how we drive people into our office. It’s about basing totally in science. So when I talked to patients and we published a paper that I know you’re aware of, that we interviewed over 200 patients about what their thoughts were, why their considerations were, they get their information, how can we best impact them as far as their understanding? And for the most part, most of the hernia repairs that we do in the groin A find first and foremost, find a good surgery.
Speaker 2 (00:10:36):
I mean, find a good surgeon. And then secondly, in if you look at the Cochrane studies in 2002, and for your listeners and for your viewers, Cochrane studies are physicians who review the data about controversial topics. They review the data in the world, they kick out studies that are not very good, the best studies in the world, they review them and they coalesce them. And then they publish ’em. 2000, 2009, 2018, for Inguinal hernias, the majority of folks who have an inguinal hernia should have a Mesh based repair. If you look at outcomes, if you look at quality of life, and indeed, and there’s been a lot of controversy, and you have been interviewed and asked a ton of times by learning groups, American College of Surgeons and sages, the American Hernia Society to give lectures about this. So I’m not teaching you anything but the consideration of Mesh and based Mesh based repairs.
Speaker 2 (00:11:30):
There have been meshes that have not done well. Let’s just say that right out of the gate. But if you look at the standard meshes that we use, and if you look at those outcomes using Mesh and groin repairs, using Mesh in ventral hernia repairs and larger umbilical hernias, most of the time a Mesh repair does very well for patients. This is not the meshes that are used for bladder slings and those sorts of things. This is not the way the Mesh is applied. But there have been bad meshes or meshes that have not done well, I should say. And then you can have complications associated with Mesh. And I do walk through, when I talk to my patients, I walk through individual patients. And there are patients who, for an OR hernia repair, might do very well with a tissue repair. And I know you’ve actually even demonstrated some of this, even robotically actually going and doing a tissue repair robotically.
Speaker 2 (00:12:22):
But you are a special surgeon. Let’s just say out of the gate, you know what you’re doing. You’re a specialist, absolutely a specialist. But if I’m going to see a good surgeon who’s going to do inguinal hernia repair in me or ventral hernia repair, I’m going to ask for Mesh. One of the patients I operated on today is a nice 80 year old lady who had a tissue repair and her tissues were not very strong. She was 80 years old. She recured very quickly. And then I saw her and I re-repaired her today cause she was inappropriate for a non Mesh repair.
Speaker 1 (00:12:54):
And I think that’s where the discussion is. One of the questions asked, very simple one is how you discuss Mesh Mesh versus tissue repair options, understanding that at least in the United States, patients come to your office already having read a lot, educate themselves, whether it’s on Facebook or something more legitimate than that. So what is your discussion? And you can talk about ventral or inguinal or both.
Speaker 2 (00:13:24):
And my discussion really starts honestly with either a discuss. I will ask them, I start describing what their issue is. I get on a whiteboard, I draw pictures on a whiteboard of what their anatomy looks like, what we want to do, what’s important in the operation. And then I will say, and let’s talk about Mesh, but I’ll come back to that in a minute frequently. And then I’ll sit down and I’ll say, tell me about what your thoughts are about Mesh. And people frequently have gone online as people will go online, people are most likely to have concerns about Mesh or people who have done their own research have failed hernias. And women, quite honestly, cause women tend to drive healthcare, they tend to drive the home. They also tend to drive healthcare. So women have done their research and we discuss what their fears are, what their questions are, what their problems are.
Speaker 2 (00:14:20):
And then we discuss the appropriateness of Mesh in their particular problem, whether it’s an Inguinal hernia repair or ventral hernia repair or umbilical or otherwise. And we discuss the literature and then we discuss the Mesh of options because there’s permanent synthetic Mesh, there’s absorbable synthetic Mesh. And then there tend to be biologic meshes in what might actually work for them. And so sometimes we’ll actually find that people will actually compromise with us. And some of the, there’s good data on at least two of the absorbable meshes good data coming out on two of the absorbable meshes. And it might be very reasonable for a good patient who would fit those categories. Let’s just say that.
Speaker 1 (00:15:05):
Yeah. I have patients that come in saying, I don’t want, okay, why don’t you want Mesh? She say, well, I want the best repair that gives me the least chronic pain. I’m like, okay, that would be a laparoscopic repair with Mesh. And they say what? Correct. So I go through data with them. There’s tissue repair is not pain free, it’s not chronic pain free. Open repair with Mesh, not laparoscopic with Mesh is better than all those in terms of outcomes. So yeah, that’s what you really want. You just want the least chronic pain, best long-term results, get a good laparoscopic repair with Mesh for your Anglo hernia. So then they start, of course, you have to speak to the patients with respect and kind of understand where their angst is. But most patients are very reasonable as long as you can explain to them the risks and benefits of whatever their personal situation is. That’s great. The problem that I see is sometimes that doctors think they’re God and they’re like, I’m going to offer you only this. And the patients feel not empowered in their own care. And so that sometimes may result in a lot of distrust or if they have any bad outcome and not becomes something personal.
Speaker 2 (00:16:32):
So I mean, I frequently, and I will just tell you because you lack support at your institution when you tried to build a hernia center, and I was very lucky, Harry Nurkin, who was
Speaker 1 (00:16:44):
Our, I’m still lacking that support.
Speaker 2 (00:16:46):
Harry Nurkin, who was our CEO, really supported me. And so we were able to collect this data. And one of the best things I ever did, the first grant I wrote when I got Charlotte was I was first author and the CEO was second author on the grant. That’s what really sprung all the data that we’re collecting now comes from the grant that he and I generated 24 years, 23 years ago. But we can look, I’m very, I’m in a privileged, I’ll say I’m in a privileged position. So we published 1500 laparoscopic inguinal hernia repairs in surgery two years ago and 0.6% recurrence rate at three years. Quality of life is good. So I can actually direct the patient’s kind of to that study and say, not everybody’s ended up perfect, but our outcomes are very good. I also too, and I’m sure you’ve operated on in many physicians, and I’ll refer to the physicians and my own partners that I’ve operated, and I’ll say like, yeah, I’ve operated on six of my partners and this is what I did for them and what they chose in your situation. And so with that, the patient’s like, well, if it’s good enough for your surgical partners, then perhaps I, it’s good enough for me. But anyway, but you can’t ignore people’s people’s what their angsts are. You can’t ignore what, even if they’ve generated what their worries comes from the internet, you have to walk a patient through that. You have to accept that. And this is their body, this is their life. And you got to take it serious.
Speaker 1 (00:18:22):
So one of the live questions is, hello doctors, I have a question about whether a tiny hernia should be repaired with sutures or Mesh. What’s your answer to that?
Speaker 2 (00:18:33):
I mean, most tiny hernias will be in your abdominal wall, like an umbilical hernia or epigastric hernia. And those can be repaired frequently, most often actually without Mesh. Yeah, those are typically suture repair. They can be done often under local anesthesia, go home very quickly. And it can be done without Mesh. Yep.
Speaker 1 (00:18:52):
Yeah, very true. And then what are your thoughts about size of Mesh and whether that helped, sorry, size of hernia in the groin and whether that is a determinant of Mesh or no Mesh?
Speaker 2 (00:19:03):
Yeah, so for the groin, the different anatomy, it’s different anatomy. If someone has a large defect in their groin, and especially if they’re an aged patient, I mean all of those patients get mashed in my hands. And I tend tried, and I use the word direct cause it is just the best data, those patients. But if you get a younger patient who has an indirect hernia and they want a tissue repair, a tissue repair should ice repair, and those patients should actually do pretty well. You can do it under local anesthesia, live sedation even, and do em open under local. Under local. Tell me about, how about if I ask you a question, tell me about your robotic tissue repairs. How is that going?
Speaker 1 (00:19:45):
Yeah, so I use it very judiciously. I’m very cautious because I’d like to introduce new technology and new techniques, but I don’t want to sacrifice it by applying it to everyone. So yeah, so small hernias, super small. The ones you can’t feel even usually it’s in females in a thin patient. So low-risk patient, it’s not a recurrent hernia, it’s not a large hernia. Patient’s not overweight and it’s a small hernia. Robotic is an alternative. So if they don’t, let’s say you’re already in there for another procedure. I operate with gynecologists all the time. I can fix their hernia repair while they’re getting ruled out for let’s say endometriosis for pelvic pain. I don’t have to put Mesh in those patients. If it’s bilateral, that’s a nice opportunity to do it robotically. Instead of two open surgeries for a small repair, just think of if there would be a good candidate for a Marcy or a small hernia repair.
Speaker 1 (00:20:46):
Then the robotic ilio pubic tract repair, which my resident termed ripped our I P T robotic ilio pubic tract repair works really, really well. I would not use it for larger hernias. I had one patient where we could not put Mesh in and she, her B M I was 34. And she has chronic pain now because what she’s actually doing is she’s ripping through it because it is a tension repair. And probably by now she has a recurrence. It’s just a matter of time and trying to figure out how to repair it. But she was overweight and I think even, and she had a medium size hernia, so she’s just tearing through the tissue and that’s probably what’s giving her the chronic pain. Yeah, it’s an option. It should be something that you can consider. But you know what, all other repairs, there are risk with it. There’s entrapment of the nerve is a major one. That general femoral nerve. Correct. You can entrap, right?
Speaker 2 (00:21:43):
Speaker 1 (00:21:43):
Yeah. Another question is how far back do Mesh repairs go? For example, have they been done decades ago? So the results of these Mesh repairs can be fall long term over decades if they have been done for a long time. Has Mesh changed in terms of what material is used to so that they’re perhaps better ones over time and oh, they also want to see what Mesh looks like. But if you come to my office, I’ll show you what Mesh looks like. But yeah, that’s a good question. Can you enlighten everyone? How long?
Speaker 2 (00:22:16):
I think that’s a great question actually. It’s been around, yeah. So there was a very famous surgeon, a guy named Bill Roth who did some of the first intestinal or gastric resections, showed us how to so bow back together again. He did. He was in Vienna. He loved music. He was a world renowned guy. He taught lots of people to came and come in and watch him. And he had this famous quote that if you could actually essentially make tissue the strength of tendon or ligament, that we would discover that the how to fix hernias. And so early on, the people use silver wire to actually make a, essentially braid, make a braid out of silver wire and sew that in. 10 has been used, a lot of other things have been used. And so silver was used before 1900 to actually reinforce the abdominal wall, especially in the groin. But most before
Speaker 1 (00:23:13):
Your time, this is before your
Speaker 2 (00:23:14):
Time just a bit, but probably the most pronounced improvement in Mesh was by a guy named Francis Usher in Texas actually is in Houston. And he is the person who invented Marx, of course is used as it comes from polypropylene. Polypropylene is a, comes from the gas industry, the oil industry. It’s a byproduct of gas. And he made polypropylene, and it’s a knit Mesh, which is, we’re still using today. Some of the Mesh, the Mesh has changed a little bit in that there is a very dense Mesh. So the weave is very tight and the Mesh is very heavy and it’s very strong. And so we’ve migrated to a less dense Mesh. So you get a bit more tissue incorporation, it’s a little less infect and those sorts of things. There’s a heavyweight Mesh and a we, people have transitioned a little bit toward mid-weight meshes for some cases. But I’ll just tell you too, we transitioned, and I’ll just say pick me. We transitioned to a lighter weight Mesh and discovered that the Mesh was too light work can work for a growing hernia, but it’s too light for the abdominal wall. And we did animal studies that demonstrated it was strong enough. But the issue was is that in over 20 months or so, it became more fragile and became to fracture. And so we had more hernia. Hernia failures.
Speaker 1 (00:24:35):
Was that the lightweight or the ultra lightweight you’re referring to?
Speaker 2 (00:24:38):
Well, it’s like depends on what you would call it, but it was 28 grams per meter square. Some would call it ultra lightweight, lightweight, but it was a very lightweight Mesh trying to eliminate as much foreign body as possible and it didn’t work very well. And so
Speaker 1 (00:24:53):
There’s a sweet spot. There’s a sweet spot
Speaker 2 (00:24:54):
Where That’s right. So a mid-weight polypropylene is tends to be what people use an awful lot of. But there are other meshes that have come in into play just because polypropylene was invented in the 1950s, first reported in 1956, and here it is 2022 for god’s sake. And we’re using the same chemical process. There are other meshes, so they’re absorbable meshes. Now there are meshes made of P T F E that are both solid sheets, which we’ve kind of gotten away from ’em. But also this Mesh looks kind of like a screen on your porch. The made of P T F E has actually worked out very well. The earliest studies in that are very, very good. And then also the absorbable meshes, which go away, one goes away, which of the most popular one goes away in about six months or so, but it leaves a collagen. You tend to make your own collagen sheet behind it. Some really good histology both in animals and in humans, which demonstrate that you kind of make your own Mesh behind it. And then there’s one that lasts more like between 20 and 24 months. And some of that data now is now coming out on that Mesh. And we don’t know. But the problem is we don’t know exactly in whom the best patients are to use
Speaker 1 (00:26:11):
That. Yeah, that’s correct. Yeah, that’s Ramshaw kind of take the same Mesh out of two different people and it may look perfect in one and kind of oxidize and destroy in the other, or in the same patient, do the exact same operation, two different patients, same exact operation by same surgeon. Excellent outcome one and chronic pain in the other. So yeah, we don’t know how to predict these. So on that note, there’s another question that says, what is the chronic pain rate of a Shouldice inguinal hernia repair performed by a volume? Is it lower than the laparoscopic repair with Mesh also by an expert?
Speaker 2 (00:26:49):
Yeah. And I think that is if you look at tissue repairs by surgeons that track their outcomes and then publish their outcomes, yeah, there it is. Part of the Cochran review, one of the Cochran reviews, they looked at Shouldice repair versus an open Inguinal hernia repair with Mesh. And the opening or hernia repair with Mesh had less chronic discomfort, it had better quality of life and a fewer recurrences. Patients were back at work sooner. But then if you compare that open inguinal hernia repair to a laparoscopic repair, and when I talk to my patients out of long-term outcomes for an opening or her repair with Mesh versus a laparoscopic repair, long-term are the same. But the short-term outcomes, typically patients are back on their feet sooner, recover faster with a laparoscopic repair compared to an open repair with mesh. But as far as Shouldice, the data, the data even for people who publish their own data, people who, so you have to be a relatively high volume surgeon to publish their own data. The outcomes are better with Mesh.
Speaker 1 (00:27:57):
Yeah. Here’s another question. In Australia, Mesh products are being approved with a post-market surveillance system. This is patient from Australia joining. Yes. Fantastic. Do you see this as the same as putting Mesh implants just to see how it works? In other words, just experimenting on patients without much prior understanding of how the Mesh will do in patients. There is no registries, there is no real way of being reported. What’s your thoughts about that?
Speaker 2 (00:28:29):
Speaker 1 (00:28:29):
Reducing Mesh products,
Speaker 2 (00:28:31):
And I think you were in this session where we had a discussion, this would’ve been about two or maybe three years ago now because of COVID at the Americas Hernia Society, when if you get a new hip or a new knee, you get a card that says, this is what you got. Here’s your number to call in. This is where you report your outcomes. And we should do the same with hernia meshes. It should be, I think it should be required. And so in Australia, one of the things about Australia, and so the Mesh controversy has hit our shores, no question. And you are waist deep in all this, maybe deeper than this is you’re a leader in maybe too deep. Well, you’re a leader in the country in this because, cause I mean you’ve heard the bell ringing and you’ve answered it. I’ll just say that and yeah, it may, it’s it is.
Speaker 1 (00:29:16):
And now they’re just stomping on me.
Speaker 2 (00:29:18):
Well, I mean, but you’re very good at it. So let’s just say that, so this is rolled up on the shores of the United States, but in Australia and Zealand and the UK, I mean, it’s not a bell. It’s a huge gong. And so in Australia, what they’ve Rives, how they’ve responded in Australia with this, and it really started with the pelvic meshes, not much the hernia meshes, but the hernia meshes have played a role in it. But the pelvic meshes are really rung to gong here. But what they’ve decided is, is that all the meshes that are on the market already in Australia are going to have to be re-certified. And you’re going to have to, and so not only do you have EU
Speaker 1 (00:29:57):
Too, right? And the EU, I think they’re doing
Speaker 2 (00:29:59):
The same. I know it’s an Australia, I’ve not seen it in the EU
Speaker 1 (00:30:02):
Speaker 2 (00:30:04):
In Australia for sure, and New Zealand, what’s happening is that the meshes that are already on the market with the F D A, you get a Mesh on the market. It’s kind of done and dusted. And then the F D A will monitor things that are reported to them.
Speaker 1 (00:30:20):
Speaker 2 (00:30:22):
But you don’t have to have post-market surveillance where you as a company report your outcomes for me. Let me pay $25 more for a piece of Mesh and then make it available for me to be able to report my own outcomes That’s happening in Australia. They’re going to have to do this. The meshes are going to have to be essentially go undergo almost.
Speaker 1 (00:30:42):
Speaker 2 (00:30:43):
And I think that’s appropriate. Anybody that goes in my body, give me a chance to report on it.
Speaker 1 (00:30:50):
Yeah, agreed. Similar vein of questions. There’s plenty of questions. By the way. Why is it that there are numerous studies regarding negative outcomes of mass repairs that consistently note the need for rigorous studies, yet we never see any of these studies being done without robust studies. How can there ever be true improvement for the patients? There is this feeling by patients that we’re not studying
Speaker 2 (00:31:14):
Anything. Did a patient write that?
Speaker 1 (00:31:16):
Speaker 2 (00:31:17):
Speaker 1 (00:31:17):
Speaker 2 (00:31:19):
They would need a job. As a research coordinator,
Speaker 1 (00:31:23):
It says, without robust studies, how can there ever be true improvement for the patients and the acknowledgement from surgeons that these improvements are necessary. You’re speaking to the choir. Here
Speaker 2 (00:31:32):
We go. Yeah, I I’m with you.
Speaker 1 (00:31:35):
Yeah, a hundred percent. It’s not like we have no studies. That’s correct. But we definitely don’t have enough to,
Speaker 2 (00:31:42):
Let me raise one issue here. Yeah. So the America’s Hernia Society, the abdominal core, Donald Wall, Donald Core collective, well, it used to be the America’s hernia quality
Speaker 1 (00:31:53):
Speaker 2 (00:31:54):
Yeah. American, Hernia, Society, Quality, Collaborative quality data that they’re collecting. One of the real issues, and I’m going to point at patients right now, so one of the issues with this is that I’ve talked to Mike Rosen. They, Mike Rosen’s done a great job with this. Ben Poulose has done a great job with this. They’ve tried to drive this as hard as they can. So this quality Collaborative that we put together, the America’s Hernia Society paid for, and now they’ve broken this off and they’re trying to drive data collection in hernia repair
Speaker 1 (00:32:22):
In the United States.
Speaker 2 (00:32:23):
In the United States, thank you very much. And so in the United States, and so surgeons can sign up, they can help collect their own data, but a lot of the data that’s entered into it is surgeon collected data. The surgeons put their own data in at our institution. Don’t surgeons never put their own data in, because I might say I prescribed an antibiotic, but I’m trying to prevent an infection versus treating an infection. If I prescribe an antibiotic, that’s an infection period. The problem with the quality collective that we’ve put together is patients aren’t responding. Patients are given the opportunity to respond. That’s true. And they’re not responding. So the data, the last study that I saw, they actually reported data when they looked at epidurals versus no epidurals, only 8% of the patients had long-term data. 8% patients were given the opportunity to report their own outcomes and they didn’t. So I think for us, yes, as surgeons, we need better outcomes. Absolutely. But we need to make sure that patients will report their own outcomes when they’re given the opportunity.
Speaker 1 (00:33:29):
Yeah. Okay. This is a two-part question. Okay. Say you have a Mesh fearing male patient with a recurrent inguinal hernia after a failed Lichtenstein.
Speaker 2 (00:33:41):
Speaker 1 (00:33:42):
So Mesh repair was done, hernias recurred, and now they’re fear Mesh. So the patient is adamant against Mesh, and the hernia is fairly large, let’s say inguinal hernia. So do you say, no, I won’t do your operation because you definitely need Mesh, you already failed Mesh? Or do you try to convince them that a Mesh repair will provide the best result? That’s part one. Wow. Part two is question after inguinal Mesh removal. No, that’s not part two. Is that part two? It is. After inguinal Mesh removal. So similar to this patient, what is the efficacy of a tissue repair? These are two different people asking similar questions. How frequently you either of you consent to doing this in your practice? So replace Mesh with a tissue repair. What are your thoughts about that?
Speaker 2 (00:34:31):
So the first question is, you’ve done in Lichtenstein, fairly large inguinoscrotal recurrence. What I would tell the patient is, is that I need to do this laparoscopically and I need to do it with Mesh. And what I would do then is as I would direct them to our data, the paper that I’ve mentioned earlier that we published now with almost 1500 patients, and over a third of those patients were recurrent after opening or hernia repair. And so our outcomes in those patients are very good. But one thing I would stress to the patient is I understand now there’s worried about Mesh. They’re worried about Mesh causing complications, worried about Mesh causing a problem. And this is, especially if it’s a young patient and that sort of thing. But my answer to that patient is the most difficult hernia is the recurrent hernia. And the most difficult hernia is the two-time recurrent hernia instead of the one-time recurrent hernia.
Speaker 2 (00:35:29):
And so for me to believe that or to look at this patient and say, Hey, I’m a good surgeon. I can do this. What I need to do is I need to fall back to the best data that we have. And I’ll just say that. And data at our institution, and I’m sure would be resembled much like yours is, you need to have this done laparoscopically by a very skilled, very skilled surgeon. If I had that, if I was in that situation, I’d call you or I’d call my partner Ken Kercher or Vedra Augenstein in my institution, and I would say, look, I just need a laparoscopic or hernia repair with Mesh. Just take care of me.
Speaker 1 (00:36:02):
Yeah, yeah. I totally agree. What patients don’t understand is a big inguinal squirrel hernia. I mean, technically you may be able to do a tissue repair on that. Let’s not talk recurrent, but man, that’s so much tension on a horrible thin tissue. So if you want to talk about chronic pain that’s going to be chronic pain, constantly try and tear through this really thinned out tissue, multiple suture layers. I mean, that’s a very painful, so the fact that Mesh is bad doesn’t necessarily mean that the tissue repair will give you a better outcome, especially for these larger ones.
Speaker 2 (00:36:40):
I completely agree with you.
Speaker 1 (00:36:41):
But I would say though, if the patient has some Mesh problem and their hernia, we’re talking groin here and their hernia is small, I’m happy to remove the Mesh and do a tissue repair. Okay. It’s not ideal, but that’s okay if it’s small and feasible.
Speaker 2 (00:36:58):
And so sometimes you get these patients who will have had an opening or hernia repair, have a recurrence and have pain, and they’re worried that the Mesh is causing their pain, but they also have a hernia recurrence. And so the first thing that that we’ll do in those patients is repair their, or hernia, laparoscopically ’em, him. I mean, you could actually go in, do a triple, cut the nerves in the groin, take the Mesh out after doing a laparoscopic repair, but often the pain that’s caused by the recurrence and simply repairing their hernia will take care of it.
Speaker 1 (00:37:33):
Okay. We’ve got some questions about Mesh implant illness or Mesh reactions. Okay. Very interesting one. So one of the questions was actually submitted prior. So let’s just start with that. And that really is maybe looking at the history of Mesh reactions because I feel like we’re seeing more of it. So the question is, do you think Mesh reactions are a modern day problem? Were you seeing patients react to their meshes in the past and in the past? It means when we started.
Speaker 2 (00:38:09):
Yeah. So I mean, it’s very uncommon and see, so let me just back this up. So everyone reacts to a foreign body. Yes. Any foreign body that you have, whether it’s a cataract lens or it’s going to be, if you get an vascular graft and you get replace a blood vessel or a Mesh, you will have a reaction to it. And you’re going to have almost always have some sort of inflammatory reaction to it. And usually it’s very localized. It’s right on the Mesh. And quite honestly, we don’t heal without inflammatory reaction. Whenever you have a cut, whenever have a laceration, you have the inflammatory phase of healing that comes in. And so when your wound becomes that’s healing becomes pink around the edges and that sort of thing, the scab becomes really, really firm. You’re having an inflammatory reaction to that. And that’s part of the healing process. And so the problem with some mesh and can be for certain individuals is that you can have a real inflammatory reaction to Mesh that may be exaggerated. Much like when you mentioned Bruce Ramshaw, good friend Bruce has talked about, you can have different reactions to difficult chemical materials
Speaker 2 (00:39:28):
As an individual. So there is no, and I shouldn’t say there are rare recordings of allergic reactions to polypropylene, which is one of the most common, or to P T F E. There’s very rare recordings of allergic reactions to those materials. Very rare. But you can develop a bit of an inflammatory reaction. But it also, it has to do with the construct of the Mesh and the individual. But as far as generalized inflammatory reaction in the body, there have been people who have raised the question of a generalized inflammatory action within the body. And I just haven’t seen that. And I don’t know if you’ve seen that and seen that.
Speaker 1 (00:40:12):
I see it more. Yeah.
Speaker 2 (00:40:14):
Yeah. Cause you get a lot of patients who come from all over to talk to you and see you about those types of things. Yeah. I’ll let you answer that question
Speaker 1 (00:40:21):
Now. So we actually published our paper on this full foreign body reaction. So every single that was removed, we looked at the pathology, a hundred percent of them had a foreign body reaction, right? A hundred percent had chronic fibrosis. These were all classic findings of any implant. Then we categorize them. How many of these people had Mesh removed because of chronic pain and how many was incidental? They had recurrent hernia or they needed, it was a me Mesh infection and therefore not truly a foreign body. Your body was not reacting no difference. It made absolutely no difference, right? What your clinical status was. The pathology was exactly the same. So that’s something that I tell my patients all the time because these lawsuits against the Mesh industry, very much focus on foreign body reaction and chronic inflammation and fibrosis, which every single Mesh product will have, regardless of why it’s being removed,
Speaker 2 (00:41:21):
Every single corn body.
Speaker 1 (00:41:23):
So that was kind of a nice kind of way to help teach the patients a little bit. But I am seeing a larger proportion of my patients requiring measurable because they are having some weird head to toe systemic reaction. They’re getting chronic fatigue, brain fog, et cetera. And then we actually present our data, and hopefully we’ll get published this year, which is looking back to see categorizing what are the symptoms, what percentage of people get these Mesh implant illness type symptoms, and then what risk factors do they have? How many of them had autoimmune disorder already? Or some type of inflammatory disease already, rheumatoid arthritis, lupus, mast cell activation syndrome, fibromyalgia, and those kind of things to try and understand a little bit better. Is there a subpopulation of patients? Are they thinner? Is there, are they more likely to be female? What are we seeing in these subpopulations that are making them potentially a little bit more reactive to a Mesh product?
Speaker 1 (00:42:33):
Based on my experience, I’m very reluctant to put Mesh in people that have really bad autoimmune disorders, activation syndrome, people that come in, they’re like allergic to a million things. One poor guy was allergic to polyester. He literally is allergic. He works in the shipyard here, and when he walks through the shipyard, his eyes start burning and tearing because of the polyester resin in the air. Oh, wow. He can’t wear polyester socks because he’ll blister. And of course he got polyester Mesh in during his laparoscopic ventral hernia repair. Wow. Poor guy. I mean, how unlucky can you be? So there are real allergies, like you said, very, very uncommon. Very uncommon. But it can happen.
Speaker 2 (00:43:21):
But when patients, but then when there’s a million hernia repairs a year in the United States, yes. Patients will have, patients will have that issue.
Speaker 1 (00:43:29):
That’s it. We, it’s hard to talk percentage when they end. The total number is so huge. So 0.1% of a million a year adds up. Right. Thousands of patients. a lot of people.
Speaker 2 (00:43:43):
Right? Yeah. So are you using absorbable mesh in your practice?
Speaker 1 (00:43:49):
We can talk about that with another question that’s coming up. Yes and no. My concern is some of the synthetic absorbables are still highly inflammatory in nature, and so I don’t want to add that. So by the pure biologics are doing better in terms of inflammation, but they don’t work for hernia repairs usually long term. So it’s a little bit of an issue that I would like to hopefully see better products out there with lower inflammatory potential, but also not as kind of poor outcomes long-term as like most biologics. Okay. Care biologics. Okay. So someone heard you talk about neurectomies. So they said Dr. Hanford mentioned neurectomy for treatment of pain. Does he support selective neurectomy or triple neurectomy because of the correct interconnection between the three groin nerves that may be residual source of pain. If selective neurectomy is done, can diagnostic anesthetic injection honed down to only resecting one nerve? That’s a patient.
Speaker 2 (00:44:54):
I was going to say, do they want to do a fellowship with me and come and do, I mean, that’s amazing. That’s an amazing, right,
Speaker 1 (00:45:02):
Right. Every week. Yeah. Love
Speaker 2 (00:45:03):
It. Yeah. If we have in anyone in whom I’m going to do, I would consider doing a triple neurectomy, they need to see an anesthesiologist, they need to see a pain specialist. And I tell people all the time, the most dangerous part of any Mesh resection or chronic pain is me. If we can have a pain specialist take care of the discomfort and leave me out of it, then terrific. But if they do an injection and they localize one nerve that’s caught like the ilioinguinal nerve, this is it a hundred percent. This is the nerve, then you can make a small incision out lateral and actually cut the ilioinguinal nerve and then see if that, and this can be done essentially under local, maybe a little sedation and leave the Mesh. Cause if you don’t have a hernia recurrence and you only have discomfort, and that’s the nerve that’s involved.
Speaker 2 (00:45:53):
If you cut that nerve then frequently with that one, translating that one nerve frequently because of the, and they were correct, you get this overlapping of those three nerves. So frequently, you mean even if you cut one of those nerves, you still have normal, essentially normal sensation. But if they inject the ilioinguinal nerve and the pain goes away, then yes, you can just cut that single nerve and be done with it. But most often when I’m operating on someone and Cause if there’s one nerve that’s causing a problem, they can just ablate it and they don’t need me.
Speaker 1 (00:46:27):
Speaker 2 (00:46:28):
And so when I’m going in, most of the time I’m doing a triple neurectomy.
Speaker 1 (00:46:33):
Speaker 2 (00:46:34):
Yeah. Cause they can’t ablate all three.
Speaker 1 (00:46:37):
What’s surprising is there’s not that much data on what happens once you do these. So we looked at our own and what we found was if you do a surgical neurectomy, right, cut the nerve for pain, neuroma, nerve entrapment, whatever the situation is, preoperative Neuralgia of that specific nerve, there’s about a 4% neuroma rate, at least in my hands, which is about the same. I think in the publications before it’s around 5%, so 4%, 5%. But if you do kind of like a prophylactic neurectomy, some people do it or the nerve is cut incidentally for whatever reason, let’s say it was in the way or you didn’t want to risk injuring it, we found 0% risk of Neuralgia, which was surprising because I’m always afraid of cutting any nerve that doesn’t need to be touched. But surprising that we saw no consequence besides numbness, but no consequence in terms of pain and Neuralgia after cutting a nerve that’s otherwise healthy.
Speaker 2 (00:47:46):
If you had to say, here are the 20 articles that’s influenced you as a hernia surgeon, that one article that came out of Scandinavia that was published in surgery where they didn’t cut the I illegal nerve in an opening or hernia period, and they did manipulated it versus non manipulated. And if you manipulated the ilioinguinal nerve and didn’t transect it, they had a 21% chance of chronic pain. And so ilioinguinal nerve, if it’s in the way it’s laying over, if I have to manipulate that nerve, I’m going to transect it. And most patients don’t know that I have. But as far as, one of the things is, as you mentioned, doing a triple, there are some people who will do a triple neurectomy inside the abdomen or in the pre peritoneal space. Yeah. So I don’t do those. And what, yeah. Cause what you’ll see is you cut the muscular branches and then your whole groin tends to expand. And so I’ve not done those because of that. And then that’s what we’re seeing now is that you may get your pain taken care of, but then your groin just all the muscles will come last. They’re paralyzed in that
Speaker 1 (00:48:51):
Area. Yeah. I started with laparoscopic triple, I think we had a little poster at sages like, Hey, you can do laparoscopic triple. We like our first four patients I think. And then my fifth patient got the donation injury. I’m like, Ooh, that’s horrible complication. So I pretty much have stopped doing that unless it’s very selective and I do it as distal as possible. But then a larger paper came out saying that it works great. And I spoke to that surgeon afterwards at the meeting, I think it was Pacific Coast Surgical Association. I’m like, I’m seeing denervations. I didn’t see you talk about it. He’s like, yeah, it happens. I’m like, but you didn’t present that. So now there’s this great paper that says laparoscopic triple neurectomy works. And that’s why with my paper, with the robotic ilio pubic tract repair, I don’t want everyone to do that repair. Yeah. Because it has problems the same way triple neurectomy does laparoscopically. And the denervation injury, you’re right, is a huge complication that’s very hard to address.
Speaker 2 (00:49:58):
You got to be careful with your trade-offs. Yeah, that’s for sure.
Speaker 1 (00:50:01):
Okay, the question, next question actually, you’ll like this one. I’m going to do this just for you. Is there a Mesh size to hernia size ratio that you use? I e, for example, under 10 millimeters should have a small to medium Mesh greater than 10 millimeters may be a large Mesh. My indirect hernia had a neck of only five to eight millimeters, but the surgery repaired it with a large 3D max, which overkill for a small hernia. Have you had pain issues in the area? So using a Mesh so large to rectify a tiny hernia could be causing pain because of scar tissue. What are your thoughts on that? I would like you to address this actually for ventral because that’s something that you’ve looked into, which is the size of the hernia versus the size of the appropriate Mesh, number one. And then also to comment on standard sizes for Inguinal hernias and why we use certain sizes.
Speaker 2 (00:50:56):
So I think that’s, these questions sound like surgeons sitting in an audience, or at least resident sitting in an audience. I mean here, the people who listen to this are pretty sophisticated.
Speaker 1 (00:51:10):
It’s pretty sophisticated. I know
Speaker 2 (00:51:11):
Pretty dadgum sophisticated.
Speaker 1 (00:51:12):
Well, brings me back every week.
Speaker 2 (00:51:14):
It’s fantastic. Yeah. So for ventral hernias, what we found is that the larger, the Mesh for the defect actually decreases recurrence and does not impact quality of life and does not increase the infection rate. And so if you’ve got a defect that’s this big, and then you put in a Mesh that’s this big versus that big, the bigger the Mesh decreases your recurrence rate. And so we put our meshes in the pre peritoneal position and the lion share the open ventral hernias that we do. So the Mesh does not touch the intestine up against the muscular or the fascial abdominal wall. But the bigger the Mesh for a ventral hernia, the better. And so a ratio of about four to one for a moderate size defect is what we found worked the best, less than three to one. And so if you have a, that’s
Speaker 1 (00:52:10):
Area right three to one
Speaker 2 (00:52:11):
Area. Area. So if you’ve got a six by six defect, so you’re 36 square centimeters for the defect, you want to be four to one is what we found works in larger than four to one. Didn’t matter for
Speaker 1 (00:52:23):
Speaker 2 (00:52:24):
For ventral hernias, less than three to one increased recurrence rate. So I want a larger Mesh for a ventral hernia. It doesn’t negatively impact me, it just doesn’t. But it impacts my recurrence rate. So for an inguinal hernia, for the most part, we use a fairly standard size Mesh. And of course if we’re operating on a smaller person, we’ll use a smaller Mesh. But our repair for the most part, if you have inguinal hernia is very standard. And so if I’m doing it open with Mesh or I’m doing it laparoscopically with Mesh, we are going to repair that whole floor. And we’re, we’re not just going to repair the one hole you have because there’s always a chance that you’ll develop a weakness just right next to it, right next to it, bilateral to it. And so you never want to come back.
Speaker 2 (00:53:13):
Cause if someone has to come back in your groin, the chance of a complication or problem or pain goes up significantly. So the re operative groin is a problem. And so I just want someone to do a standard open or laparoscopic repair in, if I’m operating on a smaller woman, smaller Mesh, but I got to cover that whole area laparoscopically or open bigger guy, I might use a really big Mesh, but I’ve got to cover that whole space where they can develop a hernia in the future because I’m never coming back. I never want them to come back.
Speaker 1 (00:53:50):
And this is based on people have actually tried using different size meshes, and there’s a standard Mesh for groins where there’s a balance between not being too big where it overlaps with a bunch of unnecessary areas and not so small that you get a hernia recurrence. So a large 3D max is pretty standard for almost every groin hernia, unless you’re a really small petite lady, like maybe a small Asian petite lady or a huge guy with a large hernia. Yep. Okay. Then can you believe our hour is almost over? Really? Wow. Right. Yeah. But we have a lot of questions, but I will respect your time. So this next question, three different people have asked. So we’re going to read all three of them. So one is, what does a data say about how Mesh ages in the body over 23rd or four years,
Speaker 2 (00:54:41):
Who are these people? I
Speaker 1 (00:54:43):
Know second similar is can you talk about complications with hybrid Mesh degrading and causing foreign bodies? And then the next similar one, I think I told you a little bit about someone has been following you and knew that you were talking at the American Hernia Society meeting. And so they saw perhaps you were talking about your data on ovitex, which is a hybrid Mesh versus stratus, which is a biologic Mesh. And what’s your experience with that? So this is about Mesh degradation and also biologic versus hybrid meshes.
Speaker 2 (00:55:21):
Wow. That’s amazing. That is just amazing. You love
Speaker 1 (00:55:25):
It. I love it.
Speaker 2 (00:55:26):
I love it. I love it. So as far as Mesh degradation, no question there is Mesh. Mesh will change slowly over time. And so we’ve mentioned Bruce. Now Bruce Ramshaw for the third time. Yes. Bruce did a really nice study demonstrating that you’ll have some chemical change in the Mesh. Over time, the Mesh has become more oxidative oxidized. They actually become a little more fragile, a little more crystalline. And so the standard Mesh that we use is polypropylene. And I’ll just say that we tried to back off as hard as we could about 15, 7, 17 years ago to using lightweight meshes for ventral hernia repair. And so one of the things that we did is we did an animal study we did in pigs, and we studied these meshes and it six, just about six months. And we demonstrated that when we harvested these meshes, these meshes were strong enough for humans to repair their abdominal wall.
Speaker 2 (00:56:22):
And I think this question that that was asked is brilliant in that. So yeah, so six months we’re like, yes, this Mesh works. We’re going to decrease the mass of the meshes. The Mesh is going to be wider pore, they’re less infect, they hold us bacteria. I mean lots of things that we studied in our lab and [inaudible], Will Cobb, Yuri Novitsky and Mike Rosen did when they work with me. And so we then immediately started using these in humans. And the problem for me is that I’ve been at the same institution for 23 and a half years and have not left because we have long-term follow up on our patients. And what we began to see is that six month follow up was not long enough. What we saw in humans at six months between a mid weight and a heavyweight Mesh and the lightweight meshes, the outcomes were the same.
Speaker 2 (00:57:09):
You get out to 12 months, they’re the same. At about 18 months there was a break. Lightweight meshes began to fracture. They became more crystal and then became crystal enough compared to the heavier weight Mesh, the mid-weight and the heavyweight meshes that they fractured and they would actually tear. And then we got recurrences for ventral hernias, not so much for groin hernias, but for ventral hernias, the ventral abdominal wall hernia. And so that question, you’re absolutely correct, and I’ll just tell you that the Tiffany Cox, when she presented this data at the American College of Surgeons demonstrating that yes, it worked in animals in six months, but in humans in short term. But between 18 and 20 months, there was a break point. And so I mean, we have to tell on ourselves. And so we actually changed what we did because of that. Yeah, the changed, we need long-term outcomes and we need the patients to help us as far as ovitex.
Speaker 2 (00:58:09):
And so I’d worked with ovitex as one of their consultants early on, just talking to ’em about their Mesh and combining some of these, the possibility of combining permanent suture in their Mesh and that sort of thing. And I’ll just tell you, we just don’t have a lot of data with ovitex at all. We, we’ve used an awful lot of strattice because we take care of a lot of very complex hernias. Patients who have infections, patients who have infected meshes, patients who have with their intestines are growing through their abdominal wall and they have a hernia. So very complex infected cases. And so we’ve used an awful lot of strattice, which is a non crosslink, so it’s kind of a native collagen, porcine, Mesh, it’s made of porcine skin. They take all the things that react out of it, and then they sterilize it. And we’ve used it in the abdominal wall.
Speaker 2 (00:59:06):
And actually, if we repair these, use this Mesh in an extra peritoneal position, don’t put it inside the intestine, against the, excuse me, inside the abdomen against the intestine, but put it just against the muscle of the fascia. Our outcomes have been very good, but ovitex is new and there’s not a lot of data with ovitex at all. And so if someone’s going to use it, I think one of the things that we have to do in America especially is looking at when we get new products on the docket, if surgeons are going to, surgeons are going to use this, they need to know what their own outcomes are. And so if a surgeon has a new Mesh and has no reported outcomes, no recorded outcomes of their own, that’s going to make me question the use of that Mesh, quite honestly. And so I think the only way we can improve is that we have to accept that we’re going to have things come out that are going to be better. But if you’re going to give up something, n if you’re going to do something new, you got to give up something old. And you got to make sure the new thing is better than the old thing. And so without any data, we don’t know. And so then it is that data that Mesh needs to be tracked for sure.
Speaker 1 (01:00:19):
This is awesome hour.
Speaker 2 (01:00:21):
Thank you. Thanks for having,
Speaker 1 (01:00:23):
I feel like I want to do it again and again. You should be like my co-host. All we do is just talk back and forth and this looks so much fun. Love
Speaker 2 (01:00:31):
It. I love it. Well, it’s so good to talk about to someone who is a leader, really passionate for their patient. Thank you. Vision advocate. No. Well, I mean, you get asked to give these lectures all over the country and before COVID all over the world about exactly what it is that you do, being one hernia expert, but also being an advocate for the people that you take care of, and you got your priorities in the priorities in the right place.
Speaker 1 (01:00:57):
I love it. I mean, now you’re experiencing how fun it is. So why wouldn’t I do this all the time? Yeah, absolutely. Yeah, it’s fun. Thank you so much for your time. I really appreciate it. You just finished surgery and came straight over and did this hour with me, so I’m very, very grateful. I hope to see you soon at some of the meetings coming up. So yeah, please, everyone, you got lots of fans here. Everyone is thanking you on these chats here and terrific. I’m very grateful so much for your time. And thank you everyone for Hernia Talk Live, our weekly Q&A. I will post the link to this so you can watch and share this awesome hour with Dr. Heniford on my YouTube channel. And I hope y’all have a nice, safe, safe evening and sorry to all the Bengals fans because LA we won. Bye guys. Bye. Todd, thank you.
Speaker 2 (01:01:53):
Thanks so much.
Speaker 1 (01:01:54):