179. Hernia Surgery Behind the Scenes

This week, the topic of discussion was:
-Operating Room
-OR Team
-Surgical Technologist
-Circulating Nurse
-Anesthesiologist
-Sterile Technique
-Surgical Preparation
-Tow-finger
-Surgeon
-Choosing Your Surgeon
-Surgical Technique

Welcome to HerniaTalk LIVE, a Q&A hosted by Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist who practices at the Beverly Hills Hernia Center. This is the only Q&A of its kind, aimed at educating and empowering patients about all things related to hernias and hernia-related complications. For a personal consultation with Dr. Towfigh: +1-310-358-5020, info@beverlyhillsherniacenter.com.

Our Guest Panelist is Juan Salazar, Certified Surgical Technologist

If you find this content informative, please LIKE, SHARE, and SUBSCRIBE to the HerniaTalk Live channel and visit us on www.HerniaTalk.com.

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Transcript

Dr. Towfigh (00:10):

Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly question-answer session. I’m here and we’re having problems with Facebook, I think because of all those issues from the weird Microsoft thing that happened online all over the world yesterday, last week. But I’m very happy today to be joined via Zoom only, not Facebook Live this time with Juan Salazar. So Juan is a certified surgical technologist. I’ve known Juan for

Juan Salazar (00:50):

Nine years, close to 10, 2015, 2015.

Dr. Towfigh (00:55):

Okay. So little over 10 years. Almost 10 years. I’m just really excited to have you on. So this is the story. Thank you. Let’s start this over. This is the story. So Juan knows I’ve been doing these Hernia, Talk Live sessions, right? And every week I’d be talking about what we’ve talking about, the topic, questions and answers and so on. And we talk a lot in the operating room. And recently, Juan has made a move to a different hospital. So I haven’t been with Juan, and I get this message and Juan’s like, you do this great stuff on Hernia, Talk, Live. Why don’t you do a behind the scenes sessions? Because so many patients go to surgery and they don’t really have a good concept of this big black box called the operating room. And I’m like, that’s exactly right. Why don’t you be my guest? So Juan is joining us from Arizona. He is a major hospital in Arizona. He used to be the surgical tech at our surgery center, which is where I do the majority of our hernias and hernia related mesh removals and things like that. Juan has seen it all. And I love Juan because he’s very intelligent and I’m very attracted to people that are intelligent. I can talk to them. And if you’re spending time in the operating room, it’s really, really a gift to have someone that’s intelligent. I’ve learned a lot from Juan, and so

Juan Salazar (02:29):

As I’ve learned from you,

Dr. Towfigh (02:31):

Welcome to my show. This is so exciting.

Juan Salazar (02:33):

I’m excited to be here.

Dr. Towfigh (02:35):

So you can follow Juan on Twitter or on Instagram? He is on Instagram at surgery tech 84, so it’s actually SX, TECH 84. He’s very funny. He’s got a lovely family. Four kids,

Juan Salazar (02:56):

Four girls,

Dr. Towfigh (02:57):

All girls. God’s trying to tell you something.

Juan Salazar (03:01):

God told me something and I saw Josephson for that.

Dr. Towfigh (03:05):

Yes, Dr. Josephson was one of our guests. Snip Snip. So we were just talking quote backstage before we went live, and then Facebook decided not to like me today. So we can’t do this as a Facebook Live, but I’ll make sure this gets posted on my Facebook page for everyone else to see and share in addition to YouTube. But the goal of today is to help figure out everything that you need as a patient to learn about, I guess, demystify, is that a good word, Juan? Demystify what happens in the operating room.

Juan Salazar (03:46):

Most definitely. Yeah. It’s not a big secret, which is people really don’t know once the verset hits, they don’t remember anything. They just remember like, oh, this is really nice, and then, oh, I’m awake.

Dr. Towfigh (03:59):

Well, so that’s important because the surgery starts in the operating room, but the patient care starts preoperatively depending on whether it’s a hospital or a surgery center. It’s still the same. You go to a preoperative area, you un clothe down to, I mean, pretty much everyone’s completely naked. We don’t have underwear and socks and so on allowed. You’re given a gown, and then after you see the surgeon and the anesthesiologist, then you’re whisked into the operating room. In that space, there’s no family members, no one can watch you. It’s purely the surgical team. During that transport, you’re often given a medication called Versed. It’s an amne amnesia, amnesiac, so you should not remember anything. Once you’re given that drug, it also calms you down. But it’s so interesting because we remember you in the operating room talking to us even, right?

Juan Salazar (05:10):

Oh, full conversations about what’s going on in their lives, like complete conversations. And they’re usually very funny patients.

Dr. Towfigh (05:16):

Patients have no idea. They don’t remember any of it.

Juan Salazar (05:21):

Isn’t that

Dr. Towfigh (05:21):

Interesting?

Juan Salazar (05:22):

Because of my role, I don’t get to see that part at the end. I just get to see them kind of wake up and get whisked off, and then I’m cleaning the room for the next case.

Dr. Towfigh (05:30):

Well, part of the role of the anesthesiologist is to make sure they don’t recall anything during surgery, and then hopefully nothing before and right after. Because for some people it can be stressful.

Juan Salazar (05:43):

It can be traumatic

Dr. Towfigh (05:44):

And traumatic. Yeah. Okay. So what’s the protocol? The nurse usually with the anesthesiologist, takes the gurney, put the patient to the operating room, and then there’s other members of the team in the operating room. You’re one of them. You’re already there usually scrubbed in and waiting, right?

Juan Salazar (06:10):

Well, what we do is my role begins usually days, days,

Dr. Towfigh (06:16):

Days before surgery. You’re like a secret service. You’re the one that goes in and makes sure everything’s ready. Exactly. When the president shows up,

Juan Salazar (06:24):

Day of surgery, I usually go in there an hour before my first surgery begins. Let’s say I’m doing a hernia with you. We start at seven in the morning. I’m usually there by six.

Dr. Towfigh (06:35):

Yeah,

Juan Salazar (06:38):

I go in there, I make sure the room is set up, make sure we have the correct instrumentation as far as the correct bed, the correct towers, the correct, yeah,

Dr. Towfigh (06:49):

Even the correct bed is important.

Juan Salazar (06:51):

Yeah, very

Dr. Towfigh (06:51):

Much so. Beds are different depending on the type of surgery patients need.

Juan Salazar (06:56):

And then how you set it up, you can set up the bed backwards so that you can actually flex the bed a certain way, tilt it or whatnot. Yeah. So the bed is one of the main components there, aside from the actual video equipment, the cameras, the towers, things like that,

Dr. Towfigh (07:11):

Because some beds you can do fluoroscopy with others you can’t are longer. Right. And some are not. Yeah,

Juan Salazar (07:19):

Some you

Dr. Towfigh (07:20):

Need to put the patients in a special lithotomy position,

Juan Salazar (07:24):

Special. You need the special ST for that. But those attachments can attach to basically almost any or bed. But yeah, I have to make sure all that is there. And then I go and actually check the list of things that we need as far as our instrumentation, if it’s sterile, if it’s not sterile, most of the time we check to see if we have the correct mesh. If it was ordered, if it was there. But we do that in conjunction with the nurse.

Dr. Towfigh (07:51):

So I usually tell you communicate with the operating room in my orders specifically what mesh I want. Exactly. And I do that both for the surgery center and the hospital for two reasons. One is it kind of reminds me what my train of thought was in planning for the patient when I first saw them, but it also somewhat guarantees that the surgery center or the hospital carries that mesh. It’s not out of stock or doesn’t have the right size or things like

Juan Salazar (08:22):

That. Or if they had to order it, they did.

Dr. Towfigh (08:25):

Yes. Sometimes they have to order it,

Juan Salazar (08:28):

And most of the time, especially at an ambulatory center, they do have to order it depending on where you’re at.

Dr. Towfigh (08:34):

Yeah. They don’t have a large variety or a large inventory. It’s expensive.

Juan Salazar (08:40):

And I mean, some places do have a, what’s it called? They do have somewhat a variety, but minimal amounts of it. So if another surgeon order it before you did well, they’re going to save it for that particular surgeon for you when you didn’t order it. I don’t know why it does play a big role because the other surgeon ordered it and you didn’t. You just assumed it was going to be there, which is why sending orders ahead of time is such a big help for everybody.

Dr. Towfigh (09:11):

Yes. I feel most surgeons do not order their mesh. Right. You operate with other people who do hernia surgery?

Juan Salazar (09:19):

Yes. Yes. And most of the time they ask, what mesh do you have? Not, Hey, I need this mesh, or Hey, I ordered this mesh. No, they just ask, Hey, do you have this mesh? I’m like, sure, give it to me. Give me some scissors. I’ll cut it to whatever size I want.

Dr. Towfigh (09:36):

Some meshes are not supposed to be cut. That was one of the cases that I did where a surgeon cut a mesh that shouldn’t have been cut.

Juan Salazar (09:45):

Yeah. Oh. Then when they put it in and they used the ProTech or whatever’s that they’re using, I’ve seen ’em use it incorrectly. I assisted in an umbilical, laparoscopic umbilical hernia put in the mesh that they wanted. They had the correct size. How about that? Big? And then they proceeded to put attack

Dr. Towfigh (10:09):

Every 0.1 millimeters. Yeah. We

Juan Salazar (10:12):

Went through two tags.

Dr. Towfigh (10:14):

Two. Oh, wow.

Juan Salazar (10:16):

For something that big. Yeah. These are my face. There have been a couple inches in between space or something

Dr. Towfigh (10:24):

Like that. Yeah, pretty much all

Juan Salazar (10:27):

The way around

Dr. Towfigh (10:28):

Made them feel better. But that really pushes the patient into severe muscle spasm at the least. At the

Juan Salazar (10:35):

Very least. Yeah. And then we talked to the reps, aren’t you going to say something because this is your stuff? They’re like, no.

Dr. Towfigh (10:44):

Yeah. Okay. So let’s review who’s in the operating room. There’s this, obviously the surgeon. Surgeon. The surgeon may or may not have a surgeon assistant or some type of dedicated assistant. Sometimes their nurses or physician assistant.

Juan Salazar (10:58):

Yeah,

Dr. Towfigh (11:00):

You have to be there. Yes. You’re the surgical tech. Now, before your generation of surgical techs, there used to be nurses that were doing the surgical tech job, right?

Juan Salazar (11:14):

My profession was before the school started popping up, it used to be an OTJ trained position, OTJ on the job training. So you got brought in and you got trained by a surgeon how to do things. We didn’t have schools. We didn’t have a curriculum to follow.

Dr. Towfigh (11:39):

Okay.

Juan Salazar (11:40):

They just pulled you in, you want to learn. They pulled you in and you started you. They taught you from zero. And I still know techs that that’s how they started.

Dr. Towfigh (11:51):

Wow.

Juan Salazar (11:51):

They started as got trained on the job, and then later

Dr. Towfigh (11:55):

On now there’s a certification for surgical technologist.

Juan Salazar (11:59):

Well, now there’s an associate’s degree attached to it. And in Texas, there’s actually a bachelor’s degree that you can get, but only in Texas, nowhere else.

Dr. Towfigh (12:12):

Okay. So what’s the process? You had to get a high school diploma first?

Juan Salazar (12:20):

Yes. To get a high school diploma first, you can either go to a jc, a junior college.

Dr. Towfigh (12:29):

Okay. Junior college.

Juan Salazar (12:31):

A junior college, and they have a curriculum there. But with that curriculum, you don’t get an associate’s degree. You just get your certification. And that particular process lasts for about two years, two and a half years. You can go to an accredited, a tech school, like a trade school that has the, which is what I did. I went to a trade school, and it’s nine months, depending on the trade school. The one I went to, it was nine months of classroom training. So I was on taking tests, learning the pharmacology, learning instrumentation, everything. Then you go into your clinicals, and with us, at least when I graduated back in 2010 in my class, we did three months of central service. So that’s what we learned. All of our instrumentation, we learned how to wash it, how to take care of it, how to sterilize it, how to wrap, sterilize, and how to make sure everything was okay for the surgery.

Dr. Towfigh (13:38):

So in addition to your work in the operating room, which is assisting the surgeon and handling, you’re basically the communication between the non-sterile world and the surgery And the

Juan Salazar (13:48):

Sterile world.

Dr. Towfigh (13:50):

The sterile world, you are sterile, and most of your work at the time of surgery is handing instruments and providing needles and scalpels and so on,

Juan Salazar (14:02):

Making sure the whole field, sterile field is maintained sterile.

Dr. Towfigh (14:08):

You set up the sterile field and you’re also in charge of maintaining it.

Juan Salazar (14:14):

Yeah,

Dr. Towfigh (14:15):

Basically going wrong. You’re the one that usually picks that up

Juan Salazar (14:19):

When you have new residents coming in and things like that, and they have no idea how to do it. And it’s happened to me where I’m setting up an X lap, just an open procedure, and a new resident comes in and he’s like, Hey, do you have my gown and gloves? I’m like, I have no idea who you are, but the gowns and the gloves are there. So they go grab the gloves, and they’re like, okay, you can throw ’em on the field if you want. And they literally tossed the whole packet on the field. They no

Dr. Towfigh (14:48):

Contaminate my, oh, that’s happened.

Juan Salazar (14:51):

That’s happened to me. That’s happened to me. Oh my

Dr. Towfigh (14:53):

Gosh. And

Juan Salazar (14:53):

I look at my and IT lens, right on my instruments, not even a place where I can kind of cover it up with the Tegaderm or something like that, right on my instruments. And I just look up and I look at the guy and look at the resident, and I’m like, did you really just do that? He had no idea what sterility was. I assuming. I thought he would, yeah.

Dr. Towfigh (15:18):

There’s a whole protocol and process about what’s sterile, what’s not, which parts of your sterile area is truly sterile, what parts are not so sterile?

Juan Salazar (15:27):

Yeah, what you can, yeah. So when that happened, I just turned around and stared at him. I turned around, looked at the surgeon, and the surgeon just looks at him, tells him, get out of the room. And we have to, obviously at that point, we have to break everything down. It delays the surgery again, restart, because now we have to start from scratch again. We have to open up a whole new sterile field on our table, open up sterile instrumentation again, do all our counts all over again, open up basically everything again. And it’s not only timely, it’s costly. Now we’re spending much more money to reopen everything again. And if we had any in

Dr. Towfigh (16:04):

The backside, you got ways of sterilizing, cleaning, packaging, everything. Yes, autoclaving. There’s a whole sterility process that there are companies that come around to audit you to make sure that your sterility process is done correctly.

Juan Salazar (16:23):

We have the joint commission, we have CMS. We have a lot of, literally every three years they’re on us, and they are nitpicky. They are to the smallest little detail, complete and nitpicky. And it can get frustrating with them when they’re in house.

Dr. Towfigh (16:45):

So other people in the operating room, usually the anesthesiologist or anesthetist, it could be a doctor, it could be a certified C, a nurse anesthetist, and then there a circulator circulating nurse. So that’s pretty much in the United States, that’s pretty much minimum in third world countries. There’s maybe less than that. There may be one anesthesiologist for multiple rooms. There may be non nurses that handle things.

Juan Salazar (17:17):

And I’ve noticed that that also goes, it changes from state to state.

Dr. Towfigh (17:22):

So yeah. So you experienced California, then you went to Arizona.

Juan Salazar (17:26):

So here where I’m at, the hospital where I’m at, we do have nurse anesthetist, we have CRNAs, but they can’t put the patient down unless the MD is in the room. Unless the anesthesiologist is in the room. The hospital

Dr. Towfigh (17:40):

Does that. Yeah.

Juan Salazar (17:43):

The anesthesiologist has to be the one literally looking over the shoulder as they put them down.

Dr. Towfigh (17:50):

They function more like residents than actual independent anesthetists, right?

Juan Salazar (17:55):

No, it’s for 20, 30 years of experience. They still have that anesthesiologist and are next to them, making sure they’re doing it correctly. And most of these CRNAs that have been there for so long, they know more than some of these anesthesiologists, but because of the laws, that’s what they have to do.

Dr. Towfigh (18:11):

Yeah, I asked about that. I didn’t understand it because at the surgery center and at some hospitals, the nurse anesthetists are very independent. There’s no doctor around that’s necessarily, but at the hospital, they’re treated like a resident. The attending surgeon has to be there overseeing the initiation and the termination of anesthesia. And I think it’s a billing issue in addition to a safety issue. I think there’s a level of anesthesia maybe that they negotiate a contract with the insurance company. I don’t know.

Juan Salazar (18:58):

It could be at that. I have no idea. Yeah,

Dr. Towfigh (19:00):

I mean, I don’t think it’s just a policy

Juan Salazar (19:02):

Because over at the surgery center, it was A-C-R-N-A was head of anesthesia.

Dr. Towfigh (19:07):

Yes, he still is. Yeah, still is. Yeah. And they do great. Patients are perfect.

Juan Salazar (19:13):

Yeah. I mean, I don’t remember Robin Ani, CNA, just ridiculously good. And he’s the one that taught everybody there how to do blocks.

Dr. Towfigh (19:24):

Yes.

Juan Salazar (19:25):

They got him into the block system. Yeah.

Dr. Towfigh (19:27):

Yeah. So yeah, that’s kind of interesting. There may or may not be a rep in the room, an industry rep that’s very dependent on the surgeon and the procedure and the

Juan Salazar (19:42):

Hospital, the disposal you’re going to be using.

Dr. Towfigh (19:44):

Right.

Juan Salazar (19:44):

Yeah. What if you’re going to use any of their implants? You definitely want to rep there.

Dr. Towfigh (19:51):

Well, the implants for orthopedics and neurosurgery, right? Am I correct in that?

Juan Salazar (19:56):

Yeah, they’re correct. They’re not correct.

Dr. Towfigh (19:58):

Why is that? They have so many different pieces, or what’s the reasoning for that?

Juan Salazar (20:03):

There is. So with orthopedics, the components, like let’s say for a total hip, they bring in, at least at the hospital where I’m at, they bring in the trays like the night before or two days before. So we can sterilize ’em half ready. And then the implant components actually, they come together before they go in the patient. And then we have to cement them to put ’em inside the patient. And sometimes either the surgeon needs a little help, or even us, the techs, we need to find out how to do it. And if we’ve never used that system before, we need the help from the reps. And they’re trusted lasers to let us know how to put things together. And it is immense help. I mean, even if we’ve done it a hundred times, the rep being there gives us a sense of ease.

Dr. Towfigh (20:56):

Yeah. It’s very complicated. They keep changing it like the iPhone every year. It’s like a new one, so you need a specialist.

Juan Salazar (21:04):

Right.

Dr. Towfigh (21:05):

So

Juan Salazar (21:06):

Yeah, we definitely need a specialist to let us know.

Dr. Towfigh (21:08):

Here’s a question. What is attack and what is it made of? And what is the advantage over sutures? So there’s different types of attacks. There’s a permanent, and the absorbables, the permanent is titanium based, and the absorbables are usually suture base,

Juan Salazar (21:27):

Like

Dr. Towfigh (21:28):

PDS

Juan Salazar (21:29):

Micro.

Dr. Towfigh (21:30):

Yeah. But you want to explain what it looks like. These hernia TAing devices.

Juan Salazar (21:36):

So the protag, which is one of more widely used one, it actually, it looks like a spring, like a small little spring diminutive. And it like cork screws through the mesh, which doesn’t rip the mesh, which is even better. And then it goes into the

Dr. Towfigh (21:52):

Soft tissue. I like those the best. It’s the old school one. They changed, not changed. They added absorbable ones, which a lot of surgeons use the absorbable meshes. I mean absorbables tax, but I don’t use absorbable sutures. I don’t see the purpose of absorbable tax. It’s just much more expensive.

Juan Salazar (22:14):

And then I think I’ve heard, I’ve read of instances where patients actually develop an adverse reaction to them.

Dr. Towfigh (22:24):

Oh, yeah. Yeah.

Juan Salazar (22:27):

It’s not common.

Dr. Towfigh (22:28):

It depends on how it’s used. Yeah. Depends on how it’s used. Not common. Yeah. So, okay, you can be honest. Who’s the best hernias surgeon? I’m just kidding.

Juan Salazar (22:40):

And I’m not realistically, because I’ve worked with you for so long and I’ve seen how quick you are and what is it called?

Dr. Towfigh (22:54):

Careful

Juan Salazar (22:55):

How much you pay attention to detail when you’re doing your surgeries. Compared to some of the other surgeons I’ve worked with, by far, you are probably the best that I’ve worked with. Oh,

Dr. Towfigh (23:07):

Thank you. Well give an example. Maybe give a little bit more

Juan Salazar (23:12):

Clarity. I work with this one surgeon who were doing bilateral ventral hernias. He decided to go open, which is fine. I mean, I didn’t know why he still used a spacemaker. So he put in a port on one end through the spacemaker, pumped it up, and that separated the ventral hernia from the rest of the tissue, or I don’t know what he did. And then it made it easier for him to see where it was at and to fix it manually. Interesting. But then he popped that on accident and he had to do the other side, and he opened another space right here. And those things, as you know, are not, they’re not cheap. They’re expensive.

Dr. Towfigh (24:03):

They’re seven, $800 each. Yeah.

Juan Salazar (24:05):

We use two of them for a case that took 45 minutes,

Dr. Towfigh (24:13):

The spacemaker, but then he went open.

Juan Salazar (24:16):

Yeah, I know. Using

Dr. Towfigh (24:21):

Spacemaker on the left and right to do a component separation, but there’s no reason for it. I mean, there’s different ways of doing things, I guess.

Juan Salazar (24:33):

And he learned it from somebody else, and he’s like, oh, it’s amazing. It just makes surgery so much easier, so much faster, which is great. But at what cost and at what cost to the

Dr. Towfigh (24:44):

Patient? This is true. This is true. And you’ve seen me make comments about that.

Juan Salazar (24:51):

I have advocated for the toe finger at my new jaw. I advocated about,

Dr. Towfigh (24:58):

Did you call it that?

Juan Salazar (25:00):

No. It was another tech. When we did the live surgery a few years ago, his name was Jeff, and he’s the one that called it the toe finger. I think He saw you do it. And then he taught me how to do it. And then we were just, that’s what we called it from then on a

Dr. Towfigh (25:14):

To. Okay. But did you call the toe finger at your new hospital?

Juan Salazar (25:21):

Oh, yeah.

Dr. Towfigh (25:22):

No way.

Juan Salazar (25:23):

Yeah, I was like, I told, oh yeah. Instead of using these space makers, what we do is we get a couple of gloves, couple of old ties, get a suction irrigator and just blow it up and it’s so much cheaper. And I told, we called it a to finger because a doctor that used to, her name is Dr. Towfigh, and it

Dr. Towfigh (25:42):

Works. He used the finger of a glove.

Juan Salazar (25:44):

Yeah, we used two fingers. I,

Dr. Towfigh (25:49):

Okay. So did they think that was crazy

Juan Salazar (25:53):

Or did they think surgeon, one of the surgeons was, no, no. One of the surgeons was like, that’s actually genius. That’s pretty smart. And he asked, how much Satan do you guys use or anything like that? I was like, if I remember right, we use probably about 60 ccs, and then we just suck it out

Dr. Towfigh (26:09):

Four times.

Juan Salazar (26:10):

60. 60. 80 ccs. Yeah. So 80 ccs,

Dr. Towfigh (26:15):

240 ccs.

Juan Salazar (26:16):

240. Oh yeah, because there’s big, there’s about two 40

Dr. Towfigh (26:20):

It says. Here’s a question. Is the spacemaker also what is used to do the retro rectus dissection in laparoscopic tap ular hernia repairs? Or is that another device? Yeah. Yeah. So the SPACEMAKER was intended to make a retro rectus space for the laparoscopic tap angle hernia repair with mesh. It has since been expanded for any retroperitoneal procedures. So some people use it for the kidneys to access retroperitoneal and do a laparoscopic kidney surgery. In the retroperitoneal space, there have been reports of using the spacemaker to make a lateral dissection to do a minimally invasive component separation for ventral hernias. But I’ve never heard of it being used for an open repair.

Juan Salazar (27:16):

I’ve never seen it used from repair other than that one time. And it kind of caught me off guard. So I was like, okay. I mean, had separated the tissue, it worked fine. I was like, okay,

Dr. Towfigh (27:27):

But it’s expensive. It’s basically a balloon, right? It’s like a straw, a really big straw, like a boba string straw with a balloon at the end of it. And you put the straw in the space where you want the balloon to expand and you expand the balloon. It’s like a breast implant. It’s a big expander tissue expander to make space behind the muscle without having to make a big incision to make the space. That’s the purpose of it. It’s a great invention. It works very well. It’s just expensive. It’s like seven, $800. And especially if you’re working at a surgery center for doing a hernia, you’re not even getting paid seven or $800 profit. So to use that, it’s a big drain. And resources plus the original spacemaker, I don’t know if you knew this one. The original one was not latex free.

Juan Salazar (28:21):

I didn’t know that. I think most of the original instrumentation weren’t latex free,

Dr. Towfigh (28:25):

So you had to make something like that with a latex free glove. Oh, you have the toe finger. I, I’m seeing a patient who had that spacemaker put in, and then it popped, but they didn’t know it popped. Pieces of plastic were in him for decades, and it got infected, and no one knew. He just was always a little sick, and no one could figure it out until he finally got really sick and they did a scan. They saw something where they went there and they saw chunks of plastic in that area.

Juan Salazar (29:08):

Wow. Those things are hard. Well, I don’t know how hard they were to pop back then. They’re pretty hard to pop now. You basically almost need a, it’s

Dr. Towfigh (29:15):

Very hard to pop. I don’t know. But I’ve seen videos on YouTube where people are showing themselves using it. The way you’re supposed to do it to prevent a lot of tissue damage is it has a little pumper that puts air and expands this balloon in the tissue space, and you got to go slowly and maybe do 20 or 30 pumps at the most. And I have seen videos where they’re pumping that thing. It’s some type of video game really, really hard so fast. And that causes bleeding and extra tissue trauma that’s not necessary. And maybe you’re overextending the balloon.

Juan Salazar (29:54):

It’s like they’re using a F, you’re trying to take somebody’s blood pressure. Yes. It’s

Dr. Towfigh (29:58):

Like it’s a very similar pump, right? Yeah,

Juan Salazar (30:01):

Yeah. Very much.

Dr. Towfigh (30:02):

You’re expanding the breakfast muscle away from the posterior fascia. And so you need to be delicate in that space.

Juan Salazar (30:09):

Yeah. When you’re thinking you’re pumping your air shoes, your Air Max shoes from the nineties, your air Jordan. Yes.

Dr. Towfigh (30:16):

Your air, Nike Air Max.

Juan Salazar (30:17):

Yeah.

Dr. Towfigh (30:18):

Did you have one?

Juan Salazar (30:20):

Yes, of course

Dr. Towfigh (30:21):

I did. You did. You’re of that generation.

Juan Salazar (30:24):

Yeah, I’m Zenni there.

Dr. Towfigh (30:27):

Okay. So one thing that I really enjoy with Juan is he’s very knowledgeable about a lot of things. Juan is Mexican, and so I love the Mexican culture. I try and practice a little bit of Spanish with him, but I also like Mexican culture and music. Juan has always been a great person to work with in the operating room because I would let him decide the music for the or, and I would get a lesson as to who these people are and what they’re singing and the history behind it and so on. So do you still do that?

Juan Salazar (31:08):

I try to, most of the doctors here where I’m at, they bring on their own speakers or they put their own music on. But every so often they start playing Spanish music and I’m like, oh, I know this song. And they would ask me, how do you know this song? Well, I was born in Mexico, so I grew up with this type of music. And they start asking me, they’re the ones that initiate the conversations like, well, who is this? What do they see? They don’t understand the lyrics. What are they saying? And I explained to ’em what’s going on and who wrote it and why they sing it a certain way. And then they’re like, I didn’t know that. Oh yeah, cool’s cool. And it’s just like they start playing it more and more often.

Dr. Towfigh (31:53):

Well, the thing is, while we’re operating on the patient, every surgeon’s a little different. There’s some surgeons, they want complete silence and you can’t talk to them. They want a complete zen to the max where there’s no discordant discussions. And it’s all just the beep, beep beep of the anesthesia machine. And just focusing on the patient. There are other,

Juan Salazar (32:21):

They don’t even talk to us

Dr. Towfigh (32:23):

And they don’t talk to you.

Juan Salazar (32:24):

And because of our training, we know hand signals that you guys use for surgeons.

Dr. Towfigh (32:28):

Yes. Like scissors,

Juan Salazar (32:30):

Pickup,

Dr. Towfigh (32:31):

Suture.

Juan Salazar (32:32):

Yeah, suture. Give me sutures. That’s part of our training. When we work with surgeons like that, we have to pay attention to their hands because they won’t tell us what they want. And all of a sudden they just stick their hand out. They do the signal, stick their hand out.

Dr. Towfigh (32:47):

Someone just stick their hand out.

Juan Salazar (32:50):

Exactly.

Dr. Towfigh (32:51):

Which means you need to know what the operation is and what they have to do next.

Juan Salazar (32:56):

And in the beginning of my career, I remember staying up late at night researching the surgery. I’m about to doming it. And I was like, okay, these are the steps. This is what I’m looking for. And it got to a point where I was researching four to five different surgeries a night. And my A DHD brain works. I tend to memorize things. And I kind of memorized the rhythm of surgeon

Dr. Towfigh (33:25):

Said, you’re very int intelligence.

Juan Salazar (33:27):

And I was able to keep up with some of these surgeons. There was these two surgeons back when I was doing my clinicals, they were two GYN surgeons, and they would talk between each other. They wouldn’t talk to any of us. And usually their cases, they would do total abdominal hysterectomies, open hysterectomies, and there’d be two techs in the room because they were so fast. And again, all what they were doing was handing those hands. And we were just, but

Dr. Towfigh (33:52):

Also, you can’t see very well when it’s deep in the pelvis doing a hysterectomy.

Juan Salazar (33:57):

No, no, you can’t. That’s why. Hard see. Yeah. So one day with them, one of the techs got sick and had to leave. So I was left alone with them by myself, and I have no idea how I pulled that off. But even at the end of the surgery, the doctors were like, you’re like an octopus. My hands were just moving back and forth between both surgeons and I was like, crap, what am I doing? I was a student. I had no idea what I was doing. Oh,

Dr. Towfigh (34:22):

Wow.

Juan Salazar (34:23):

So I managed to pull that off. I don’t know how, just magic, but being able to do that, it showed me that I was able to understand different surgeries and be able to pick up working with any surgeon.

Dr. Towfigh (34:39):

Well, that’s interesting. With your job, which is you do work with different surgeons, it could be the same operation. You get to see it done multiple different ways, different techniques, different attitudes. Everyone has their own personality on top of that. They use different sutures, different matches, and you kind of have to know how each doctor does it because no two doctors operate the same.

Juan Salazar (35:01):

No, no, no. You could have been trained by the doctor that did the case before you, you’re still going to do it different. But you found an easier way, a faster way, or you found your way of doing it better for yourself. And yeah, us as texts, we do have a cheat sheet. We have your preference card that gives us your,

Dr. Towfigh (35:25):

It’s like my recipe.

Juan Salazar (35:27):

Yeah, basically your recipe

Dr. Towfigh (35:28):

And or ingredients. Ingredients for the recipe.

Juan Salazar (35:31):

Right. But we have to know what the case is going to be like, how you’re going to work it. And we have to figure that out.

Dr. Towfigh (35:43):

Yeah. So that’s interesting because I would say a lot of people who are looking to like, oh, which doctor should I go to? I feel like the techs know really well. Who’s a good surgeon, who’s not a good surgeon. They don’t see the patient, but they can see the quality of surgery done. Do you want to maybe explain how different surgeons offer different quality of surgery? Like how they handle the tissues or the attitude towards their incisions? Even their dressings. I feel like

Juan Salazar (36:17):

I miss your dressings, by the way. I miss the dressings that you, I dunno if you still do ’em, but I miss the way you.

Dr. Towfigh (36:23):

I do. I do. Oh,

Juan Salazar (36:24):

Perfect. Beautiful. So today I work with one of our trauma surgeons. He is one of those guys that he just wants to cut. He just wants to get in and

Dr. Towfigh (36:40):

Start moving, saving lives. That’s his role.

Juan Salazar (36:42):

That’s his role, exactly. And he is, because of what he does for a living, he’s very aggressive when it comes to opening up.

Dr. Towfigh (36:54):

Common surgeons tend to be,

Juan Salazar (36:56):

Exactly. So it’s one of those, they just want to rip open almost. And when it comes to closing, they’re not too worried about a plastics closure. They just want to make sure that everything is sealed. Everything is watered. Staple,

Dr. Towfigh (37:07):

Staple, staple.

Juan Salazar (37:09):

Yeah, exactly. Staple, staple, staple. And then the dressing time,

Dr. Towfigh (37:12):

Time dressing,

Juan Salazar (37:15):

Dressing has to look nice because that’s what the patient sees, the dressing. But then there’s, there’s surgeons like you, surgeons, like a few of the surgeons that I know where you take the time, you do the plastic slow, do the subcuticular sutures take,

Dr. Towfigh (37:31):

We have the time because the patient’s not trying to die on us. Yeah,

Juan Salazar (37:34):

Exactly. This doctor, even though he is a trauma surgeon, these cases were scheduled.

Dr. Towfigh (37:44):

Oh, yeah.

Juan Salazar (37:45):

But he takes the same approach as a trauma. He just wants to get in and get out as quickly as possible, make sure the patient’s okay. And there’s nothing wrong with that. There really isn’t anything wrong with that. But when you’re also a teacher and you’re teaching your residents on how to do things, if they’re not going to be trauma surgeons, they’re going to be regular surgeons. They’re going to go into general or whatever specialty they decide. You want to teach ’em how to close. Correct. How to take better care as to the aesthetics of it, especially when the patient might be 17, 18, 19 years old or younger patient as opposed to a 50, 60 something year old patient aesthetics are going to play a big part in their role.

Dr. Towfigh (38:31):

Yeah. I mean, I see patients, I’m like, oh, that’s a really big incision for problem that you had. Or I asked them, how much bruising and pain did you have after surgery? Because to me, that implies a little bit more of a heavy handed surgeon or maybe a surgeon that maybe not as careful. So I do think techs have a really great insight tell story, should I get my shoulder done with, they can see all the different orthopedic doctors and how they do shoulders, for example. And hernias are the same.

Juan Salazar (39:04):

Anything is the same. I can give you an example. I was a few years ago, my mom was having a cyst removed from her face facial. Don’t ask me how I managed to get into the OR where she was going to have her surgery. I just managed to get in there. Found out I asked around who the tech was that worked with that particular doctor, and I just asked him, I was like, Hey, can you meet me after work or whatever? Let me buy you dinner. Lemme buy you something to drink and let me just pick your brain about this surgeon.

Dr. Towfigh (39:37):

Good. That’s very nice.

Juan Salazar (39:40):

And they were, sorry, they’re knocking on my door and they were, what’s it called? They were accommodating. Oh,

Dr. Towfigh (39:53):

Really? Helpful to get to tell you

Juan Salazar (39:57):

To tell me what, who, and yeah, the tech told me what if it was my mom, I’d go to this surgeon instead.

Dr. Towfigh (40:06):

Well, some surgeons have a big name and other surgeons are a little under the radar, but they’re really good.

Juan Salazar (40:13):

Yeah. Oh yeah, for sure. So this particular surgeon was one of their top surgeons there, but their closures weren’t great. And again, my mom was having facial surgery, so I just told her, you know what? Yeah, go ahead. Have a surgery with this guy, but ask if you can get a plastic surgeon to come in close. And she did, and they managed to accommodate it, and she got a plastic closure on her face.

Dr. Towfigh (40:42):

One of the things I tell my audience is when you go for a hernia surgery, you always get a second opinion. It’s always good to get a different viewpoint, let’s say, from a different doctor and so on. But the one thing that I recommend, and I don’t know how to do it, is I say, okay, find a surgeon that you trust and just kind of trust that they’ll do the right thing. But I kind of know which surgeons are good surgeons and are not based on seeing ’em in the operating room or whatever. But I think the nurses and the techs really know the most because they see multiple surgeons. Whereas I don’t go into other people’s operating room when they’re doing hernias to kind of see how they do hernia surgery. I don’t,

Juan Salazar (41:33):

It’s not kosher. It’s not cool because it feels like you’re looking over their shoulder

Dr. Towfigh (41:38):

Just trying to, yeah. I think if I go, I actually try not to go. There are doctors that are operating and I go in there to say hi and stuff. It’s like a country club, but they’re usually GYN that urologists, they’re not doing a hernia surgery. I feel like if someone’s doing a hernia surgery, I specifically, even though I would want to go in there and say hi, I almost force myself not to because I don’t want them to think that I’m looking over to see if they’re doing it right per my standards. I don’t want ’em to think that, so I just don’t, and therefore, I really don’t know how surgeons do herniated repairs.

Juan Salazar (42:14):

It’s honestly a mutual respect thing. And the same thing, believe it or not, even with us as techs, we do go in and help out other techs to open the case or do whatever, but once we look at their set, once it’s our setting up, we tend to just either walk away because it’s their table, their setup

Dr. Towfigh (42:37):

Territory,

Juan Salazar (42:38):

What works for them is for them. However, when I’m learning a new procedure and there’s a tech setting up, I go and I pick their brain about it and I look at their setups and I was like, just to get an idea of what it’s going to be like. And then once you do one, you start messing with the setup yourself. You start changing things left and right. Then you figure out what works for you. But you as a tech, you don’t go. It’s like, oh, hey, you know what? It’d be easier if you do this and put it there just because the doctor’s going to use it. You don’t do that. It’s just a mutual respect between texts. It’s like, this is your setup. This is your case. You are

Dr. Towfigh (43:19):

Going to do this.

Juan Salazar (43:21):

If you need help, I’ll be more than happy to come and help you. But other than that, it’s totally your case.

Dr. Towfigh (43:26):

Okay. There’s some questions that have been submitted ahead of time. I want to get a moment to go through it. What is the impact of surgical technologists on the positive outcome of a surgical procedure? That’s a good question.

Juan Salazar (43:38):

That is a good question. The first thing would be sterly. A good surgical technologist will make sure everything is steroid. If everything is sterile during the surgery, everything goes as planned. Nobody breaks really at the end, there’s a much lower rate of infection. And that to me is a completely positive outcome.

Dr. Towfigh (44:09):

So important.

Juan Salazar (44:11):

The sterility is key. It’s the number one thing, because then I learned this today, a third of hospital related death is due to sepsis, due to, due to what’s you called, infections. And if you’re in the operating room, we play a vital role in diminishing that. So if we just see something that becomes contaminant and we don’t say it, we don’t say it because, oh, it’s in the corner. It’s like nobody’s going to touch that area. That’s not good. That’s not being a good tech. So we have to speak out, especially because spoken up, especially when surgeons touch something, unc, Sarah, and we tell ’em, Hey, you need to change your glove. Like, no, no, I didn’t touch anything. I’m like, well, I still feel more comfortable if you change your glove, we have to speak up.

Dr. Towfigh (45:01):

Yeah. That’s very, very important. You’re kind of like the police of the operating room when it comes to really. But also a good operating room is one where everyone feels safe talking and saying to the surgeon or to whoever, Hey, it looks like you just brushed against an unsterile area or your gloves. There’s a hole in your glove or something like that,

Juan Salazar (45:27):

Which happens quite a bit because you don’t realize that you cut your glove, you open your glove or whatnot. But us as techs, we really have to keep an eye out.

Dr. Towfigh (45:39):

How have the competencies required from operating room technicians? Technologists changed according to the increased adoption of minimally invasive surgery like robotics.

Juan Salazar (45:53):

With robotics, it’s definitely a learning curve even for us.

Dr. Towfigh (45:58):

So you had to get trained for robotic surgery.

Juan Salazar (46:01):

I had to get trained for robotics. So once, obviously at the surgery center, we don’t do work. We didn’t do robotics. At least we didn’t do when I was there. I don’t know if you guys have bought one there yet or not. I’ve heard stories.

Dr. Towfigh (46:11):

We will by next year. Yeah.

Juan Salazar (46:13):

So when I went over to the hospital over there, when I was in Pasadena, I got trained in robotics. They actually brought in a rep. They brought in a unsterile, things that we can use, instrumentation, things like that. And it took me three days. They taught me for three days how to set up the robot, how to set up the field, how to, and not just for one procedure, but for various procedures, anything from a hernia to a lab app, an appendectomy, a cholecystectomy, and something with prostate. Prostate, something with urology, GYN things. They taught me as much as they could in those three dates.

Dr. Towfigh (47:03):

And

Juan Salazar (47:04):

It’s a lot. I’m not going to lie. It is a lot. Much like with surgeons, I’m sure.

Dr. Towfigh (47:09):

Yeah, it’s a long process. But I think you guys are bored when we do robotic surgery. No,

Juan Salazar (47:20):

It

Dr. Towfigh (47:21):

There’s less for you to do.

Juan Salazar (47:23):

Well, aside from less for me to do, I am able to actually look at the surgery and learn what it is that’s happening. That way when it happens again, we do the surgery again. I can actually, I learned the anatomy, so I try to pick up on the anatomy.

Dr. Towfigh (47:40):

Okay. That’s kind of cool. Yeah, you do see it very well.

Juan Salazar (47:43):

Yeah. I try to pick up on the anatomy, especially because let’s say another surgeon is doing the case, but he’s not doing it robotically. He’s going to go just laparoscopically. I can tell where he’s at and what he’s going to need.

Dr. Towfigh (47:56):

What is a typical educational path of surgical technologists and what are the most challenging tasks they’re called to perform? You already talked about your path. What are the most challenging tasks that they’re called to perform? Like heart surgery,

Juan Salazar (48:14):

Cardio surgery, cardiovascular surgery. There is definitely a specialized field for them. I have never had the wish to learn hearts.

Dr. Towfigh (48:23):

What about neurosurgery or brain? The brain.

Juan Salazar (48:26):

I’ve done brain surgery, believe it or not, brain, when it comes to brain surgery and neurosurgery and ortho spine surgery, ortho, neuro, very similar. And I also remember our spine surgeon that we used to work with there at the surgery center. How fast we’re moving.

Dr. Towfigh (48:46):

Yeah, very good.

Juan Salazar (48:47):

And same thing with the neurosurgeons I used to work with at the other hospital. It’s the same type deal. It is just, you’re just paying more attention to what they’re doing because obviously the brain is right in front of you. When you see a skull open and you see somebody scooping out a tumor out of a brain, you’re like, oh my God, what is going on? And when I was learning that, all of a sudden the patient started to seize and I was like,

Dr. Towfigh (49:12):

Really?

Juan Salazar (49:13):

The doctor was so calm. We had ice in the back, like ice water being turned in the back. The doctor just turned looked at me. It was like, oh, just give me some ice water. And very calmly, no panic, no nothing. They start putting ice water in the brain and the seizure stopped. Kidding and kidding. The doctor turned around and looked at me. So whenever you see an open brain and somebody’s having a seizure, just throw some ice water. It’ll stop.

Dr. Towfigh (49:39):

Okay. Julie noted. Only in We talk live, you learn these lessons. Lessons.

Juan Salazar (49:45):

If

Dr. Towfigh (49:46):

You ever see an open skull with a brain sticking out and the patient seizing ice water,

Juan Salazar (49:51):

Ice water works every time

Dr. Towfigh (49:52):

Ice work for everything, I give ice packs to my patients. So

Juan Salazar (49:57):

I still have the ice pack that I got from you.

Dr. Towfigh (49:58):

Aw.

Juan Salazar (50:00):

With the little blue one with the, yeah.

Dr. Towfigh (50:01):

Yeah, they’re good. They’re

Juan Salazar (50:02):

Good. Yeah, they’re good. I still have it. And one of the other hardest things that we do is trauma. Yeah,

Dr. Towfigh (50:08):

Trauma. I would say yes. Because that can be anything, and it needs to be fast.

Juan Salazar (50:13):

Yeah. I was working at a trauma center before over in California, and I remember chart, the charge nurse told me, Hey, go pick this case. Go put it in the or. I’m like, okay. I had no idea what it was. I went, I picked it, I put in the OR and then the phone rings. I pick it up like, yes, start opening. I start opening like, okay, who’s going to be the tech? And then all of a sudden I see the patient get rushed in. I was like, oh, I’m the tech

Dr. Towfigh (50:43):

Crap. So

Juan Salazar (50:44):

I just finished opening up, started doing all my counts as fast as I could, and this particular patient had his carotid cut.

Dr. Towfigh (50:53):

Oh, no. Blood from the brain on that side.

Juan Salazar (50:59):

Right. So from opening to counting to actually being already in the surgery took about three and a half minutes, and I’m counting probably sponges. Probably have good 30, 40 sponges. And then I’m also counting about 130 instruments.

Dr. Towfigh (51:24):

Yeah. Yeah. There’s no time to do all the stuff you normally do for elective cases.

Juan Salazar (51:30):

We have to, we as techs, we have to do it, especially in a trauma. In any trauma. Yeah.

Dr. Towfigh (51:38):

Higher risk of foreign body, what do you call it? Objects being left. Yeah, objects that are being lost in the body. Yeah. Oh

Juan Salazar (51:45):

Yeah.

Dr. Towfigh (51:45):

Retain. Retain foreign body with trauma. Yeah. Retain.

Juan Salazar (51:49):

And so we have to keep account on everything, especially our sharps, our sutures.

Dr. Towfigh (51:55):

Yeah. Okay. What are the essential techniques to prevent infections in the operating theater? I

Juan Salazar (52:04):

Don’t touch anything that’s blue.

Dr. Towfigh (52:08):

I mean, that’s what I tell the medical students, right? Whatever’s blue, stay away.

Juan Salazar (52:12):

Don’t touch it in any surgery center, any hospital, anything. Whenever we open anything, it’s always going to be blue. I don’t know why. I think

Dr. Towfigh (52:22):

What’s unique with the operating room is everyone has their role. It’s kind of like the military a little bit. Everyone has their role. There’s usually a boss, which is a surgeon that maintains the demeanor of the operating room. You always want to be that surgeon that allows for a safe environment in the OR for everyone who’s working there to be very patient centered and patient focused. This podcast is focused on hernia care, but I love that you thought about the patients and their need to kind of understand what goes on in the operating room. But if you want to give a couple different tips or advice to someone who’s planning on having hernia surgery from your standpoint, what would you say?

Juan Salazar (53:14):

Go to Dr. Towfigh.

Dr. Towfigh (53:17):

Thank you.

Juan Salazar (53:18):

Go to Dr. Towfigh for sure. Beverly Hernia Center, by far, one of the best surgeons I’ve ever worked with. Secondly, do your research. Find out what type of hernia it is that you have, what are your options? And don’t be afraid to talk to your surgeon. Don’t be afraid to ask him, what’s going on? What are really my options? Does it have to be surgical with hernias? It has to be surgical. 99% of the time, I’m assuming. Well,

Dr. Towfigh (53:50):

Some surgeon, let me ask you this. This is an important question. Some surgeons, those patients go to them, right? Laundry list of questions. They want a certain, let’s say, no mass repair, and the surgeon makes ’em feel bad for asking those questions or is rude or disruptive. Do you see that, that same attitude of surgeon, are they still good surgeons in the operating room, or does it matter what their personality is versus how their surgery is? Is there a correlation?

Juan Salazar (54:25):

There’s not a direct correlation. I’ve seen it both ways. I’ve seen it where they are extremely nice, very patient, horrible surgery, but it does not translate to the surgeries. Yeah. They’re like, oh my God, what are you doing?

Dr. Towfigh (54:37):

Yeah.

Juan Salazar (54:38):

And then there’s other surgeons that are complete, pardon of my French from, and they are just amazing in the room, but they’re also, they go in with a plan and they’re like, okay, this is what we’re doing and this is what’s going to work for this patient, and that’s what we’re going to do, period. End of story. I don’t care what anybody else says. I know what’s best for my patient. And that’s great. Being a good advocate for your patient, knowing what you

Dr. Towfigh (55:05):

Yeah. The ones who have a good plan, plan A, plan B, they come in thoughtful. I think that’s a very good point. That’s a great way to choose a surgeon. The thoughtful surgeon.

Juan Salazar (55:17):

When you have plan A, plan B, plan all the way to Z, you’re going to be, you’re in good hands because anything can happen in surgery, but not every doctor has a plan for what’s going to happen.

Dr. Towfigh (55:32):

That’s true.

Juan Salazar (55:33):

So when you have a doctor that’s like, okay, we’re in here. This hernia is not what I thought it was going to be. We got to switch it up and we’re going to switch our approach. We’re going to do this, we’re going to do that, or we’re going to convert it into an open one, because that’s going to be best for them. When you know, have a good surgeon, that’s when you know can have a great outcome.

Dr. Towfigh (55:51):

That’s a good point. That’s a very, very good point. Yeah. This was a good hour.

Juan Salazar (55:58):

Has it already been an hour? It’s been an

Dr. Towfigh (55:59):

Hour.

Juan Salazar (56:00):

Oh my God.

Dr. Towfigh (56:03):

How fun was that?

Juan Salazar (56:05):

It was amazing. It was fun. Really fun. Should

Dr. Towfigh (56:06):

We do it again?

Juan Salazar (56:08):

Oh, I would love to. I would so love to. Yes, most definitely.

Dr. Towfigh (56:12):

You’ve been great, Juan. I really miss you.

Juan Salazar (56:15):

I miss working with you too. I miss you as a person. I miss actually speaking to you. I miss just running into you in the middle of the hallway, just catching up.

Dr. Towfigh (56:25):

Thank you so much. I’ve learned a lot from you, and I hope to see you again.

Juan Salazar (56:29):

You will. You will. I guarantee you, you will

Dr. Towfigh (56:32):

Drop by.

Juan Salazar (56:34):

Will do. Thank you so much, Dr. Towfigh.

Dr. Towfigh (56:36):

Alrighty. And that’s the end of our hour, Hernia Talk Tuesday. Thank you for joining me. I will make sure, even though we couldn’t do this as a Facebook Live this time, damn you, Facebook, I will upload the YouTube video onto Facebook so you can catch up on it and also know that all these episodes will be on YouTube for you to share and watch and follow. If you like podcasts, please go to my podcast and subscribe and leave a review so that other people can also find us. And you can find both me and Juan on Twitter and on Instagram. I’m at Hernia doc and Juan is at Surgery SX Tech 84.

Juan Salazar (57:23):

84.

Dr. Towfigh (57:24):

Okay. I’ll see you around. Say hi to your family. Thanks. Take care.

Juan Salazar (57:29):

Bye. Bye.