217. Pros & Cons of Open Hernia Surgery

This week, the topic of discussion was: 

• Open Surgery
• Laparoscopic Surgery
• Robotic Surgery
• Inguinal Hernia Repair
• Ventral Hernia Repair
• Loss of Domain
• Ehlers Danlos Syndrome
• Connective Tissue Disorder
• Autoimmune Disorder
• Blood Thinners
• Women’s Hernias
• Watchful Waiting
• Hernia Surgeons Alliance
• Clinical Trials
• Watchful Waiting

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, call +1-310-358-5020 or email info@beverlyhillsherniacenter.com.

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

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Dr. Towfigh (00:00:10):
All right. Hi everyone. It’s Dr. Towfigh. Welcome to yet another episode of Hernia Talk Live. Thanks to everyone who’s joining me on Facebook Live at Beverly Hills Hernia Center and I guess via Zoom. But as you know, you can also follow me and catch up with all these Hernia Talk Live episodes on Instagram X and Facebook. And this and all past Hernia Talk Live episodes are captured on YouTube. So if you like to watch them, share them, do them while they’re driving, YouTube’s a great way to do it. Plus we also have a podcast. So I would like to share with you, give me one quick second. Let’s go back. The fact that today we have a guest, Dr. Kaela Blake is joining us today from the University of Tennessee in Knoxville. She is a very gifted, minimally invasive surgeon who does a lot of abdominal wall reconstruction and hernia surgery.

(00:01:17):
You can follow her on Instagram at Kaela.blake.md. But one thing we will be discussing a lot of as well is the group that she is very closely aligned with, which is the Hernia Surgeons Alliance. And that can be followed also on Instagram @herniasalliance. So with no further ado, welcome Dr. Blake.

Dr. Blake (00:01:45):
Thank you. Thank you so much for having me. It is an honor. And just for a shout out to all who’s listening, Dr. Shirin Towfigh, she’s been a leader in our field and we look up to her, especially as women hernia specialists. She has really helped pave the way for all of us. So just right back at you at your hard work and dedication to improving patient care and we appreciate it.

Dr. Towfigh (00:02:10):
Thank you so much. So I first met Kaela at one of our surgical society meetings. You had done a fellowship. If you can talk to me a little bit about what you learned in your fellowship and then how that’s changed the type of career that you currently have.

Dr. Blake (00:02:25):
Sure. I was kind of, if you will, a late bloomer. I wasn’t sure exactly what I loved, but I knew I loved the abdominal wall and the challenges with it. And when I finished all of my training, I wanted to be better at the abdominal wall and I wanted to learn everything I could to take as best care as I could to patients. So I did two fellowships actually. I did my first fellowship in minimally invasive bariatric foregut surgery at Dartmouth while I was researching abdominal wall specific fellowships too. And so I did one year foregut bariatric surgery. And then after that I went to Cleveland Clinic and I did a dedicated just abdominal wall focused complex hernia fellowship. So I did two. So I got to train with excellent people at both places, learned a lot of skills from both Dartmouth MIS and Cleveland Clinic Ab wall.

(00:03:22):
And then my original plan was to, as faculty, do both bariatric weight loss surgery with abdominal wall and help take care of the whole patient. Yeah, that was my original plan. But I got to Tennessee and there’s way more hernias out there in the world than there are people needing weight loss surgery or the volume was different. And so my clinic got super overloaded volume-wise in terms of hernia patients, so I decided just to focus on hernias and let my colleagues that do bariatric surgery do bariatric surgery. So I don’t do any bariatric surgery, I just focus on abdominal wall, but that is my background.

Dr. Towfigh (00:04:01):
But you know enough to know who would be a good candidate and be able to gear them towards the right algorithm. Let’s say they need to lose weight. You’ll know exactly how they should go about that.

Dr. Blake (00:04:14):
Right, correct. And I do, yes, I do a lot of just big reconstructions and a lot of patients who have had bariatric surgery to help get them to that point. And so I’m always looking at how their bariatric reconstruction was done, if there’s any internal hernias, and I’m very thoughtful about the anatomy of bariatric surgery and making sure that all the mesentery is closed, the defects are closed. We’re taking care of every aspect of the patient’s anatomy, abdominal wall, and inside.

Dr. Towfigh (00:04:46):
Amazing. And did you know you were going to do hernia surgery when you first wanted to become a surgeon? Did you have any inkling about that?

Dr. Blake (00:04:54):
No.

Dr. Towfigh (00:04:56):
Yeah, everyone says that. I would say maybe this generation, the current graduating generation maybe would say hernias, but yeah, it’s so hilarious how. I feel like the topic or the specialty chose us, we didn’t really choose it necessarily.

Dr. Blake (00:05:15):
Yes.

Dr. Towfigh (00:05:16):
Yeah.

Dr. Blake (00:05:16):
I’m curious to hear your story.

Dr. Towfigh (00:05:18):
Oh yeah, I have a story.

Dr. Blake (00:05:21):
I would love to hear it.

Dr. Towfigh (00:05:22):
There’s

Dr. Blake (00:05:22):
Definitely

Dr. Towfigh (00:05:23):
A story. There’s definitely a story. Did you know you

Dr. Blake (00:05:26):
Were going to be a hernia surgeon?

Dr. Towfigh (00:05:28):
Not at all. In fact, I detested hernia surgery mostly of the groin because I really didn’t, I think, understand it very well and I didn’t like the exam very well. And so it was one of those things where it’s like your lack of confidence and knowledge in it made it so that you were just less likely to do it. And then my first job was at the county, LA County USC, the largest county hospital in the nation. And yeah, the first patient was a mesh infection patient that no one wanted to own. And I was like, “I’ll help this patient. Why is no one helping this patient?” And then I started inheriting more and I got involved with the American Hernia Society. I’m like, “Wow, there’s so much out there that I didn’t know as a resident that I started learning.” I knew the surgeons, and I went to the American Hernia Society meeting and I met those surgeons.

(00:06:33):
Dr. Amit was there, Dr. Nehus was there, Dr. Schuldeis was there. I’m like, “These are people that I read about.” So I thought that was cool. And then I decided to do as much. Well, I didn’t decide. Most of the hernias were then filtered over towards me at the county. And then after six years of doing that with my next job, I said, “I only want to do hernias.” They’re like, “Okay, fine.” So that was my story. Definitely was not something that I was looking into doing. I was the minimally invasive surgeon doing acute care surgery. That was my thing. Saving lives. Now I just improve lives.

Dr. Blake (00:07:23):
Yeah. Yeah. No, I think it’s so interesting because there’s just such. There’s a hernia and then there’s a hernia, and then there’s the complications from the hernia. As surgeons, we all take care of patients with hernias. And it’s just interesting how the really complicated, challenging, or just the anatomy that we don’t quite understand. The groin is very tough. I learned something new still every single day I’m operating on the groin. It’s just interesting how some of us are just drawn towards it and some of us just hate it.

Dr. Towfigh (00:07:56):
Yes.

Dr. Blake (00:07:56):
And I’m one of

Dr. Towfigh (00:07:56):
The people. I’m totally drawn towards it, and that it’s a complete 180 from where I was as a resident.

Dr. Blake (00:08:03):
I

Dr. Towfigh (00:08:03):
Agree. So today’s topic is to discuss the pros and cons of open surgery. And both of us are minimally invasive surgeons, which is kind of unique because we need to also talk about pros and cons of open surgery because we do offer it to our patients. And I feel like there’s so much push towards doing everything robotic nowadays. There are surgeons that I encounter that it’s as if they’ve never done open surgery before. Everything has to be done robotic. Today, for example, literally today, I had an 80-plus-year-old male that came to see me, and he’s a doctor himself. So he literally said, “I want open surgery.” This is a groin hernia. “I want open surgery. I don’t want general anesthesia. If you can do it without mesh, great. If you need mesh, whatever.” It’s like a larger hernia. I’m like, “You need mesh.” And I saw that he was already scheduled for surgery, but he is like, “Yeah, my surgeon agreed.

(00:09:10):
Open surgery, no general anesthesia. We can do it under sedation. But my surgeon just switched jobs, is no longer working in this state, so I found you.” But before he found me, he went to the partner of that surgeon, and that partner said, “Oh no, robotic surgery. You need robotic surgery,” which is not true. He does not have to have robotic surgery. And the doctor was just like, at least according to the patient, he was not offered anything but robotic surgery. And so I was like, “That’s exactly what we’re going to talk about today is it’s an educated patient. He’s a doctor himself. He’s over 80. He doesn’t want general anesthesia, totally legit. This is an elective operation, and he’s seeing a perfectly good surgeon, but that surgeon will only offer robotic surgery.”

Dr. Blake (00:10:10):
Yeah. Yes. This is a big question to unpack.

Dr. Towfigh (00:10:17):
Yeah. So let’s start early. What percentage, and we’ll break it down. There’s ventral, which is the abdominal wall, and there’s inguinal, which is the groin pelvic area. So of the ventral, the abdominal wall, what percentage of your patients are performed in an open fashion?

Dr. Blake (00:10:40):
I do 70% open.

Dr. Towfigh (00:10:42):
Open. And this is a fairly invasive surgery, trained, fellowship-trained surgeon. Yeah.

Dr. Blake (00:10:48):
Correct. Yes. 70 / 30 would be my split.

Dr. Towfigh (00:10:52):
And the reason for you doing them open is usually because?

Dr. Blake (00:10:56):
Usually it’s because this is either the size of the defect and I really need to wrap abdominal mesh back to the psoas muscles, and it’s sometimes –

Dr. Towfigh (00:11:09):
Giant. Giant hernias.

Dr. Blake (00:11:11):
Yeah. I specialize now mostly just in the loss of domain giant stuff. That’s mostly what I’m doing.

Dr. Towfigh (00:11:19):
I hope you work out and get massages. That’s a big toll on your body.

Dr. Blake (00:11:24):
I do a lot of yoga every day, every morning. And a lot of time it’s redo, it’s redo retromuscular. And there’s a lot. Sometimes these patients have had just lots and lots of surgeries and the scar tissue, the adhesions are just too much for robotics. And I think I’m faster open. Not safer, but I can do more with my hands in terms of adhesiolysis than I can with the robotic instruments. And so if that’s what the patient needs, that’s what I’m going to do. But yes, I’m trained minimally invasive. I do a lot of robotic ab walls for who’s eligible and who’s interested, but that’s not what the majority of my practice is now. Yeah.

Dr. Towfigh (00:12:13):
Yeah. Okay. Shifting to the groin pelvis area, what percentage of those hernia surgeries in your practice are done open?

Dr. Blake (00:12:25):
Probably 70 / 30 the other way. Probably

Dr. Towfigh (00:12:29):
70%

Dr. Blake (00:12:30):
MIS and 30% open.

Dr. Towfigh (00:12:32):
Yeah, MIS being minimally invasive surgery. So either laparoscopic or robotic qualify for that.

Dr. Blake (00:12:38):
Correct. Isn’t

Dr. Towfigh (00:12:39):
That interesting?

Dr. Blake (00:12:40):
Yes.

Dr. Towfigh (00:12:41):
Yeah. So why do you not choose open for the groin most of the time?

Dr. Blake (00:12:48):
Good question. Yeah, for just a straightforward first time hernia, my go-to is to offer a minimally invasive approach. Generally, it’s more for quicker recovery, smaller incisions. The hernia surgery guidelines do recommend if the expertise is there. Potentially there’s a less chance for pain if we’re doing a minimally invasive approach compared to an open approach. Honestly, I do think if you’re a technically precise surgeon, you’ll have the same outcomes whether you’re doing an open or robotic. If you know where the nerves are, know where the planes are, I think you can have an excellent result either way. But the guidelines do say overall as a population, there’s slightly less pain in the minimally invasive group. And then for women, being able to really look at the femoral space and address that if I see it. So I do offer a minimally invasive, but if there’s a large inguinal scrotal hernia, older patients who don’t want anesthesia, if we’re doing any other type of operation at the same time where it just makes sense to do it open, then I have no problem doing it open.

(00:14:03):
Should dice repairs, I like to offer tissue-based repairs as well.

Dr. Towfigh (00:14:06):
Amazing. That’s very good to know. It’s very hard to find surgeons who do offer the shouldice or some type of open non-mesh repair. Yeah.

Dr. Blake (00:14:17):
That’s what I like about hernias. Everybody’s hernia is different. Everybody’s story is different. Everybody needs slightly different approaches, even though we all use the same skillset and knowledge of anatomy. Everybody needs something slightly different. So I do think it’s appropriate to do what we need to do to give the best care for the patient.

Dr. Towfigh (00:14:36):
You kind of alluded to the pros and cons of open surgery. So recovery tends to be better with the laparoscopic repairs or the robotic repairs. Incisions tend to be smaller, but oftentimes for the complicated ones, you can do more open and maybe a more complete job open. What about patients who need either on aspirin or on some type of blood thinner? What’s your protocol for offering open versus laparoscopic surgery for them?

Dr. Blake (00:15:12):
Is the question for the groin still or for ventrals?

Dr. Towfigh (00:15:15):
Both. Both, yeah. Does that change what you offer them? Is there a benefit to open or laparoscopic?

Dr. Blake (00:15:23):
I would say for ventrals, that doesn’t change. My approach is mostly based on what they need. And if I know I can give them a better repair open, I can get wider mesh coverage, I can really safely take down scar tissue. I just do it open. Aspirin, I don’t really ever stop aspirin. I do hold anticoagulation, but I do keep aspirin going. For groins though, I think that the groin space when you’re developing it, they do. If someone’s on anticoagulation and you’re going to consider an open approach versus minimally invasive, if they’re a good candidate, I would prefer the minimally invasive because you’re not making a big subcutaneous spot pocket where they could develop a hematoma. So I think a minimally invasive approach is slightly better for someone on anticoagulation to decrease the risk of a hematoma. We’ve all had some of those people on blood thinners that have had an open Lichtenstein approach for

Dr. Towfigh (00:16:25):
Groin

Dr. Blake (00:16:26):
And they get a hematoma in their groin. And it’s not that they need another surgery, but it is kind of annoying to have to deal

Dr. Towfigh (00:16:32):
With the bold. It’s an important question to review with the patient because there’s so many people getting cardiac stents and other operations that require long-term blood thinners, Eliquis, Plavix, Xarelto. What else is there? All those different. There are all these new drugs too that come out that. And in my part of the world, they take a lot of supplements. So whenever you have omega-3 fatty acids and vitamin E and all those, that really makes them bleed.

Dr. Blake (00:17:06):
Bleed more?

Dr. Towfigh (00:17:06):
More than aspirin. Yeah, it’s pretty impressive. So we make sure we specifically ask about omega-3 fatty acids and vitamin E and injections. How that

Dr. Blake (00:17:15):
Comes across that

Dr. Towfigh (00:17:16):
In my

Dr. Blake (00:17:17):
Patient population. I’ll have to start asking that.

Dr. Towfigh (00:17:19):
Yeah. I did have a patient booze a lot, which is

Dr. Blake (00:17:25):
Good for the

Dr. Towfigh (00:17:25):
Heart.

Dr. Blake (00:17:26):
Yeah, that’s good. I had a patient who was on turmeric in aspirin, and I noticed this patient bled a lot more than normal than I

Dr. Towfigh (00:17:35):
Would pick. Yeah, ginger turmeric can cause bleeding as well. Yeah. Some of the vitamin B complexes can cause a little bit of bleeding. Not as much as the other. The big ones are omega-3 fatty acids and vitamin fish oil. Those makes me a lot.

Dr. Blake (00:17:53):
Do you change your practice based on open or minimally invasive with blood

Dr. Towfigh (00:17:58):
Thinners? Yeah, I do. Like you, not for the open or laparoscopic ventrals. I think they’re equally similar. My personal concern is I agree with you 100% because for the groin where you make the incision and you make all these different planes to get to the hernia, there’s a lot of areas where you can bleed from and you can get a massive blood clot or hematoma in the groin. And so there’s less tissue trauma with a laparoscopic surgery than open. So I think the chance of bleeding and causing a hematoma or bruising is much higher with the open surgery for the groin than the laparoscopic. However, the amount of space that you develop to make this hernia, if you do bleed, the amount of bleeding that happens with a laparoscopic hernia can be critical. I’ve had patients that. Actually, a friend of mine today just came by and was explaining how there was a patient that came to the ER, not his patient, but who bled and was hypotensive in the ER from a recent laparoscopic hernia repair.

(00:19:19):
So the critical bleeding issue I think is very important, and you never want anyone to die from an elective hernia repair. So because of that, and I’ve seen a handful, very few, but I’ve seen a handful that critically bleed, need blood transfusions, they pass out, they drop.

(00:19:40):
I don’t like to do laparoscopic surgery on patients that definitely need their blood thinners. If they can be off of it for a really long time and on both ends of the surgery, fine. But most people, they were two or three days before surgery and then maybe three to five days after surgery. And to me, it’s still too risky. So I’d rather they just bruise and get a hematoma, which is contained because the skin will only expand so much and they’ll bleed, I don’t know, a cup or two, whereas they can bleed like a gallon. That’s

Dr. Blake (00:20:19):
True. That’s a good point.

Dr. Towfigh (00:20:21):
So I actually do the reverse of what you do, but I know most people are worried about the typical patient, which is for open surgery they’ll bleed. But I just feel like the risk of death, which an older patient won’t tolerate that much blood loss, a younger patient will pass out maybe because you’re bleeding and you have no idea until you. Right.

Dr. Blake (00:20:46):
That is a good point. If there is bleeding, it is more serious if you are doing a minimally invasive approach because there is just a bigger pocket on the inside that we create and there’s not something to tamponade and put pressure on it the way the skin puts pressure on it.

Dr. Towfigh (00:21:02):
Yeah,

Dr. Blake (00:21:03):
That’s true. And normally the blood –

Dr. Towfigh (00:21:04):
That’s my bed.

Dr. Blake (00:21:06):
Yeah, that makes sense. And normally the blood vessels that bleed in the skin from an open approach are smaller little blood vessels that’ll stop, but

Dr. Towfigh (00:21:13):
On the inside – And the pressure from the skin closure will

Dr. Blake (00:21:18):
Stop it.

Dr. Towfigh (00:21:19):
Unlike the scrotual. The scrotum will bleed forever because that skin will just expand. And so the big scrotal hernias, that’s going to be a problem. You got to be really, really careful to educate the patient. I call them every single day and I make my nurse FaceTime them to make sure that they wear an external compression over the scrotum to prevent the scrotum from just expanding and filling the blood. If you ever know any male that’s had that, it’s like a water balloon that they have to walk around with for months, and it’s just the worst experience. So prevention is really important for those patients.

Dr. Blake (00:22:02):
I agree.

Dr. Towfigh (00:22:03):
Yeah. Okay. Question about, you know what? Let’s go over to some questions by the patients. Let’s do that.

Dr. Blake (00:22:14):
Sounds great.

Dr. Towfigh (00:22:15):
Some of the patients turned in some questions and I’ll share them with you. They’re questions I’ve heard before. Okay, question number one. This is cute. Can I insist on an open surgery even if my surgeon doesn’t recommend it?

Dr. Blake (00:22:38):
Yes. The answer’s yes. The whole point of a hernia surgery is to improve your quality of life. And if there are reasons to do one or the other, and there are pros and cons, and there’s not a hard, true way where every time we have to do it this way to get the outcomes. Long story short, yes. There’s pros and cons either way. So you just have to pick what’s more important to you in terms of open versus minimally invasive. And then find a surgeon who has the skillset to do it the way that you’re interested in.

Dr. Towfigh (00:23:17):
Yeah. I can imagine there are plenty of situations where a laparoscopic surgery can be done just as well or almost as well open. I don’t know if the reverse is true. Would there ever be a situation where an open surgery would just be the absolute wrong thing to do? I mean, I guess in patients with.

Dr. Blake (00:23:46):
I think the only time I can think where an open surgery is inferior to a minimally invasive surgery. One would probably be a known femoral hernia.

Dr. Towfigh (00:23:58):
That

Dr. Blake (00:23:59):
Is much harder to give a durable repair for in an open

Dr. Towfigh (00:24:04):
Approach.

Dr. Blake (00:24:04):
It’s just weird and clunky, and we as a specialty are not as good at repairing those open as we are minimally invasive.

Dr. Towfigh (00:24:13):
Agreed. Yeah, that’s very true.

Dr. Blake (00:24:15):
That’s probably one. And then the other hernias I would say would be hernias in small spaces. I don’t know if this patient’s talking about a hiatal hernia. Those are much more challenging open. We have better visualization and it’s a much quicker recovery, minimally invasive. I

Dr. Towfigh (00:24:33):
Would say Ehlers-Danlos syndrome. So people that naturally do not heal well, probably you’re doing a disservice by cutting through muscle and so on, that they will already have a weakened muscle system and poor healing. So maybe those would be patients where the open surgery would be vastly inferior and doing anything open would be a disservice to the patient.

Dr. Blake (00:24:59):
I actually have a patient coming up that has a connective tissue disorder

(00:25:04):
And the hernia is lower, but I do not want to do. And it’s a big hernia. It’s a big one, but I don’t want to do a big open incision on this person because of what you just said. I’m a little worried about cutting through fascia that’s together. So I’m going to start minimally invasive laparoscopically and try to take down all the adhesions that I can and then just make a smaller incision. I think to get the mesh to wrap as far as around that I need to, I think I will need to open. Plus this patient has already had two prior pre-peritoneal repairs with two priorities. So I do need to use my hands for all the scar tissue that’s going to be there, but I want to keep this as small as possible for that reason, for connective tissue disorders. Those are

Dr. Towfigh (00:25:52):
Complicated patients. Oh

Dr. Blake (00:25:54):
Gosh.

Dr. Towfigh (00:25:55):
They’re even going to get hernias from your laparoscopic or robotic scars.

Dr. Blake (00:25:59):
Yes. Yes. They’re planning to close those spots with a permanent suture. Yeah. Very good. That’s a good question though that that patient brought up.

Dr. Towfigh (00:26:12):
Okay, let’s go to the. Let’s go.

Dr. Blake (00:26:17):
I also, just to follow up on that same question, you’ve probably seen some rare hernias in the sciatic notch. Oh,

Dr. Towfigh (00:26:27):
Sure.

Dr. Blake (00:26:28):
Yeah. Those rare pelvic

Dr. Towfigh (00:26:29):
Hernias. Yeah.

Dr. Blake (00:26:31):
Weird pelvic. Yeah, obturator hernias, stuff like that. I think minimally invasive. You can just get down into smaller

Dr. Towfigh (00:26:37):
Spaces. Although I did have a Grinfelt hernia. It’s the one right underneath the rib, the lumbar hernia. And the patient was so thin ampetite. It was just closer to go through the skin back here than to go all the way from the belly button towards the back because it’s right there. So I did do that open because I’m like, you’re so standard. It’s right there.

Dr. Blake (00:27:05):
Yeah. Yeah, that makes sense. Yeah. But

Dr. Towfigh (00:27:08):
Otherwise – I would say though, sometimes patients do a lot of research and they figure out they’re bent on a certain type of operation and they want to go to the surgeon and say, “I want this operation.” Not understanding that maybe that’s not the right surgeon to do a certain. I mean, there are surgeons where they’re very gifted laparoscopically or robotically, but they should not be doing open surgery. For the groin especially, I would say. I think that’s just a different skillset than for maybe a ventral. So maybe that would be a time when I would not want the patient dictating the technique because the surgeon may not be comfortable or skilled doing that specific technique.

Dr. Blake (00:28:04):
Yes, that’s a good point. And that’s a good point for patients watching, just as we all do, us doctors, we’re patients ourselves too. We do have to advocate to ourselves. And when we go see doctors, I think we do need to ask in your skillset, do you do a lot of these? Is this

Dr. Towfigh (00:28:23):
Something

Dr. Blake (00:28:23):
You’re comfortable with? So if there is a specific technique that you really want done, not every surgeon is trained to do every technique out there.

Dr. Towfigh (00:28:33):
So

Dr. Blake (00:28:34):
Really taking it upon ourselves as the patients to do our research and make sure that you’re picking the right surgeon so that you’ll have the outcome that you want because not every surgeon has the same skillset.

Dr. Towfigh (00:28:45):
So for ventral hernias, you mentioned the giant hernias are usually the ones that you end up doing. That seems like your go-to, and therefore a large percentage of your patients are done open. Those are just, I would say, either not a good idea or impossible to do laparoscopically or robotically. Yeah, just they need a true reconstruction. But what about the smaller hernias, like a little belly button hernia? Do you recommend those open? Do you still do those laparoscopically or robotically and why?

Dr. Blake (00:29:17):
Good question. Yeah. If they’re really, really small in someone who doesn’t have obesity, then I would recommend just a primary repair with a stitch if it’s something super small.

Dr. Towfigh (00:29:30):
Small incision, hide it in the belly button.

Dr. Blake (00:29:32):
Yeah, exactly. Keep it simple. Most people, probably 60, 70% of people, that’ll be all they need for a long time. There’s slightly higher chance it could come back without mesh, but for most people, it’ll probably be fine for a long time. If it’s a bigger belly button hernia over two centimeters, three centimeters, or it’s someone with obesity or someone wants to lift a lot of heavy weight, I use mesh and I do it minimally invasive. Yeah. Oh, either

Dr. Towfigh (00:30:01):
Laparoscopic or robotic. I feel like there’s so much hype about laparoscopic surgery, robotic surgery, ETEP, TAR, all these different operations that I’ve literally had patients that have come to me with a belly button hernia that I could not even see. It’s like seven millimeters, not even joking with you. And she saw a community surgeon that I know, and he said, oh no. Oh, by the way, she had two kids and she didn’t noticeably have a diastasis, but for some reason he though that she had a diastasis. Again, seven millimeter umbilical hernia. And he’s like, “Oh no, this needs a full reconstruction. You need a robotic surgery.” He sent her to a robotic surgeon in town and the lady was like, “I don’t think that’s true.”

Dr. Blake (00:30:55):
Why am I here? Sounds like a lot.

Dr. Towfigh (00:30:57):
She can’t see me. She’s like, “I’m not a surgeon, but it just didn’t sound right to me. He wanted me this massive reconstruction for this little Audi that I have.” And it was small. I mean, it was small. I could not believe that someone thought it was appropriate to reconstruct an abdominal wall for a seven millimeter umbilical hernia.

Dr. Blake (00:31:19):
Yeah. That brings us to kind of a philosophical question. I was talking to another surgeon at one of our conferences recently about if you see a hernia, we all know the circle. Gosh, I’m blanking on the –

Dr. Towfigh (00:31:36):
Vicious circle?

Dr. Blake (00:31:37):
Vicious circle, yes.

Dr. Towfigh (00:31:39):
That

Dr. Blake (00:31:39):
Means if you get a hernia –

Dr. Towfigh (00:31:41):
Vicious cycle.

Dr. Blake (00:31:42):
Vicious cycle of the hernia repair. So basically if you get a hernia fixed and it comes back, the next operation that you get, the chance of it coming back is even higher, and you just get in this vicious cycle where the hernia. So anyways, we’re just talking to each other. Should we, for those smaller, straightforward, easy hernias, should we be doing a good durable repair on these upfront? Or should we be approaching this kind of stepwise fashion, like simple hernia, simple repair. If it comes back, we do something. So it was just kind of a philosophical question. And I’m curious where you are on that spectrum and yeah,

Dr. Towfigh (00:32:23):
What are your thoughts? I think about that a lot because you do see these women or men that have loss of domain like you’re mentioning. And if you ask them the story, it all start with a little belly button hernia, right? Correct. And then it tore open, and then they did it again, and then tore open, et cetera. So every single patient that I have that I redo, we’re very diligent in looking at their operative reports and diligently getting it. And I read it with a critical eye, like what could have been improved? And oftentimes they use number one proline or they use Vicryl stitch or something like that where it’s just the wrong choice maybe for that patient or they didn’t appreciate that it was within a big diastasis or it recurred, they though, oh, we’ll just try it again and re-stitch it again when it’s already recurred.

(00:33:24):
Not understanding now’s the time to introduce mesh. There are all these questionable decisions that were made that in retrospect you can be like, oh, well, maybe if they had done an X this way or that way, it would’ve prevented this vicious cycle.

(00:33:42):
I think that’s what happens. It’s this incorrect decision-making. They want to be good with the patient. Don’t worry, I’m just going to put a little piece of mesh. Well, little piece of mesh doesn’t work. We know that. You’re not trying to appease to the patient and then giving them an inferior operation, then it recurs. I mean, every so often you’ll get the Ehlers-Danlos patient or the patient that has a connective tissue disorder where you just have to be much more aggressive with how you address it. But in the average patient, I feel like the decision-making was wrong. It’s not so much that this vicious cycle was. Or maybe the patient’s chronically constipate or are always coughing and no one’s addressed their hiatal hernia or their postnasal drip or whatever the situation is that’s constantly causing them to tear. Sure.

Dr. Blake (00:34:40):
Yeah. No, I agree with that. I agree that when I see patients after multiple, multiple repairs and I read the op notes, it’s normally a lot of the same approach each time and nothing is changing in their approach. So not that the first or maybe second approaches were probably perfectly reasonable,

Dr. Towfigh (00:35:02):
Perfectly

Dr. Blake (00:35:02):
Appropriate, something small, something simple. And for most people, that’s all people need. But when it starts coming back once, even twice, we need to do different things. And that’s true. I’m seeing that different things aren’t being done when people have to get surgery several times.

Dr. Towfigh (00:35:19):
Yeah, I totally agree. And sometimes it’s the same. I was talking with an insurance company actually, an executive from an insurance company, and he was complaining about how much surgeons charge for certain operations. And I said in-network versus out-of-network, they were unhappy with out-of-network surgeons. And he was like, “I’m out-of-network. I assume you’re in-network because your employer is in-network, but the charge differential can be great.” So he was asking me, “You should be in-network.” I said, “Let me explain to you why I can never be in-network as a private practice surgeon.” I said, “I see a patient that has had a hernia repair by an in-network surgeon. It recurred. So they go back to the same surgeon and they have another surgery, surgery number two, and it recurred. And then they go back to that same surgeon, and that recurred. Now the patient is traveling to see me because they’ve failed three hernia repairs.

(00:36:39):
Now remind you, that surgeon has got paid three times. They got 3X of their surgery. And then if I stay in network, then I have to re-repair this surgery for the fourth time and get paid 1X. How is that

Dr. Blake (00:37:00):
Fair?”

Dr. Towfigh (00:37:03):
And he’s like, “Yeah, you can never go in-network.” This is a major executive of an insurance company. And he is like, “Oh yeah, no, you can’t. No.” I’m like, “That’s 80% of my practice is someone else’s patient. So it’s not fair for me to get paid the same amount as a person who did the first surgery. When you’re doing revisional surgery, it’s not the same.” Yeah.

Dr. Blake (00:37:34):
Yes. Gosh, insurance company. Yeah, it’s difficult. The CPT change in 2022 I think helped a little bit in terms of they count recurrences, they count the sizes. That is helpful. But like you said, it doesn’t count for the fifth time or the second time. It doesn’t account for how challenging it is.

Dr. Towfigh (00:38:07):
And

Dr. Blake (00:38:08):
Sometimes when I need to do just a big reconstruction just to be done with the cycle and to stop it, hopefully, at least for a long time, sometimes insurance companies will deny it or say that they didn’t need this, yada, yada. And it’s just like, do you want this patient to keep having their hernias and you keep paying for the hernias?

Dr. Towfigh (00:38:31):
Yeah.

Dr. Blake (00:38:32):
Or do you just want to pay us for an ab wall reconstruction and be done with this? So that’s something that I

Dr. Towfigh (00:38:38):
Deal

Dr. Blake (00:38:38):
With frequently.

Dr. Towfigh (00:38:40):
Since we’re talking about insurances now, I actually had this discussion. I said, “How is it cool that you as the insurance company, Mr. Executive, are okay paying 3X for that surgery, but you’re not okay paying me, let’s say 2X or whatever to do the right operation, right?” What

Dr. Blake (00:39:00):
Did he say?

Dr. Towfigh (00:39:01):
Okay. Well, what he said was, “Yes, you are absolutely right. But they don’t care. They don’t look at it. They look at it as a per incident payment. They don’t look at it as the global, this patient now incurred hundreds of thousands of dollars that we could have saved if we sent the patient or allowed them to travel or do whatever, allowed them to go out of network to someone who’s an expert. They only see it as a per transaction cost and not as the global.” And he didn’t have an answer for me as to why they don’t look at the global expense of that patient to them.

Dr. Blake (00:39:46):
I mean, it’s intuitive. I’m not an executive, but that’s intuitive, right? I mean, that’s

Dr. Towfigh (00:39:53):
Why

Dr. Blake (00:39:53):
Probably as a country, we’re in a lot of debt from healthcare because there’s a lot of waste in healthcare that happens. But we’re getting into politics.

Dr. Towfigh (00:40:04):
It was a fascinating discussion. I could talk to. Well, actually, you’ll be at the American Hernia Society meeting.

Dr. Blake (00:40:10):
Yes, I will.

Dr. Towfigh (00:40:11):
In Denver next week. I’ll see you there.

Dr. Blake (00:40:13):
Perfect. We can keep going.

Dr. Towfigh (00:40:16):
So you’ll be there with many other female surgeons of your generation who have aligned together and developed the Hernia Surgeons Alliance. Can you tell me a little bit more about this? Now, I’ve already had. Who’d I have? Jenny. I think Jenny was one of our guest panelists, and she talked a little bit about the Hernias Alliance. But why don’t you reintroduce it to our audience because I’m a big fan and love everything you guys are doing.

Dr. Blake (00:40:50):
Thank you. I would love to. Yes. So there’s a group of about seven of us that are all fellowship-trained hernia specialists. We are all dedicated to this field. Yeah, and we all just love taking care of hernias. We’ve noticed when we’ve been going to the conferences over the years, as we listen to the research and the data being presented, we noticed that there’s differences in outcomes between men and women. We see that just the way we treat women, the way we approach a woman with a hernia is sometimes the same as a man, and there’s differences. So anyways, in the data, women have worse outcomes than men. And we have found that as a field, we haven’t done a great job of figuring out why. And so us as just women surgeons, we wanted to help figure out why. And so our whole mission is just to research women with hernias, take care of them, and help improve the outcomes for women.

(00:41:52):
So it’s not that we don’t care about men. Of course, we all take care of men, but we want to really understand the differences between our male patients and our female patients and see if we can help improve the outcomes of both.

Dr. Towfigh (00:42:07):
Yeah, it’s so interesting. People don’t know that women, for the same exact operation, women have more chronic pain and worse outcomes than men. It’s been reported. Everyone’s like, “And women do worse.” And we’re like, “Okay.” And

Dr. Blake (00:42:23):
Then that’s it.

Dr. Towfigh (00:42:24):
Stop. The stops there. No more queries as to why that is. Why do you think that is?

Dr. Blake (00:42:30):
Correct. Oh, gosh. I don’t really know. I really don’t have an answer, but I have some assumption. I have some guesses. And also there’s a really great study out of the Michigan Quality of Collaborative that looked at outcomes for women, and they did a really nice analysis of men and women. And they found more pain in women, more readmissions, and more just adverse events, more just complications. And yeah, that was just interesting. Why? And when you look at the demographics of the types of hernias between men and women, women, they tended to have the larger hernias, they tended to have more recurrent hernias, and they tended –

Dr. Towfigh (00:43:12):
For the ventral abdominal ball.

Dr. Blake (00:43:13):
Ventrals, yep. And they tended to have ventrals in more atypical spots, so more suprapubic, which kind of makes sense, more C-sections, and more high up even subxiphoids. The men had more umbilicals. So women, it was in different locations. Men were more right in the middle. Yeah. And women were less likely to get mesh, more likely to get a minimally invasive approach than a man. And again, it’s a big, huge –

Dr. Towfigh (00:43:46):
That’s all over the place. Yeah.

Dr. Blake (00:43:48):
Yeah, it’s just interesting. So women, the hernias are bigger. They’re in different male or atypical positions. They don’t tend to get as mesh as much. They do tend to get more minimally invasive approaches. Just little nuances. So to answer your question, I don’t really know, but it seems like we are treating women a little differently, and we just don’t know, especially women who are younger, want to have kids. They tell you they want to get pregnant. We all are not quite sure how to take care of these patients. And we want to do the best thing for the hernia, but we are concerned. We don’t want to set them up for a problem with the mesh later on in pregnancy. So that could set them up for another hernia if we’re not putting a mesh in. So I think pregnancy plays a role. Hormonal issues play a role.

(00:44:34):
We all know that there’s hormones on the abdominal wall. It stretches during pregnancy, comes back when you’re normal sometimes. And we don’t quite understand how hormones play an impact on the abdominal wall. There’s a study showing women tend to have higher rates of, I think it was ACL, either MCL, ACL. Sometimes it was looking at soccer players, women. And when they’re on their periods, they tend to have more injuries to their ligaments because

Dr. Towfigh (00:45:02):
Of

Dr. Blake (00:45:02):
Changes. And so I think just similar with the abdominal wall, I’m wondering if there’s just a time in a person’s menstrual cycle that we should be repairing these or not repairing these.

Dr. Towfigh (00:45:11):
Yeah. I had a lady in the military and she was explaining how you’d have to put on several hundred pounds of a backpack and then jump out of a helicopter onto the ground. Her pelvic floor is completely mush. Everything is loose and so on. She’s like, “Female body were just not made to do some of the things.” But anatomy is very different. The anatomy is different. The way the nerves are distributed are different. Hormones, like you mentioned, are different. Women are more likely to get autoimmune disorders, so that seems to play a little bit of a role as to that.

(00:45:58):
In my experience in our study that we published, women are more likely for the groin pain, which is what I’m mostly interested in. And the pelvic pain, they’re less likely to be considered to have a hernia. Gynecologists still don’t believe women can get hernias. There’s a good proportion of them that don’t know women can get inguinal hernias. Don’t know how to examine them, don’t know what symptoms can cause them. All they do is chronic pelvic pain, chronic pelvic pain, chronic pelvic pain. And then they’re more likely to be on just given narcotics. We had a huge disparity in terms of men versus women in my population for the same exact symptoms. The women were on narcotics and men were offered surgery. It’s just crazy how that is. So the Hernia Surgeons Alliance, you can follow them on Instagram, right? You can donate. You’re a nonprofit, right?

Dr. Blake (00:46:59):
We are a nonprofit and we are working on setting up a way to donate to our cause. We are working on setting up some really high-powered clinical trials, which we’re very excited about. Happy to talk about those. We also have a Spotify podcast that you can follow called Core Conversations. Listen

Dr. Towfigh (00:47:20):
To some of those episodes. Those are really good.

Dr. Blake (00:47:23):
Thank you. Yeah, thanks. We’re excited about them. So we’re trying to do a lot of different things just to elevate outcomes for women, help each other as a community as well in terms of women hernia surgeons help us also get the training that we all need and education to help us take better care of our patients.

Dr. Towfigh (00:47:44):
What clinical trials are you planning for?

Dr. Blake (00:47:49):
I’m so excited. We are working on three different ones. Right now, I’m working on the protocols and working on IRB. We need to do watchful waiting for women with minimally symptomatic or asymptomatic inguinal hernias, like the VA study in men. We are working on finalizing that protocol and sending it in. So

Dr. Towfigh (00:48:13):
Annie Ellers was on our podcast and she was talking about doing that. Is that with the Michigan group?

Dr. Blake (00:48:21):
Yes. Annie and I have been on the hernia committee within SAGES with one of our groups. And so over the last couple years we have been talking about this study together. And I know she’s doing a lot of great stuff at Michigan. And we’re just at the very beginnings of planning on this trial, so we will have some meetings set up to discuss it. Literally today, Jenny and I were talking about talking to Annie and Dana Tellum and seeing if we can collaborate more on this project. But yeah.

Dr. Towfigh (00:48:53):
Sounds great. Well, count me in as an investigator on that because I see tons of women with groin hernias. And every single day I have to have that discussion. It’s like, well, in men, this is the data. And it’s crazy that still in 2026, we have no data on whether it’s safe not to operate on inguinal hernias in women. It just shows how little we know about inguinal hernias and what happens to it in women.

Dr. Blake (00:49:23):
Right. A big part of that study was we were talking back and forth, should we include women that have an asymptomatic or minimally and symptomatic femoral? Are people comfortable watchful waiting these? And the long story short, we all don’t really know the natural history because we haven’t studied it. So we are planning to include femoral hernias in the watchful waiting as long as it’s no symptoms, minimally symptomatic. It’s not something painful or incarcerated. And we’ll see.

Dr. Towfigh (00:49:55):
That’s gutsy. Wow.

Dr. Blake (00:49:57):
It’ll tell us the answer. And if we need to stop the trial or stop because of femoral issues, we will stop it. We’ll be safe. We’ll have a DSMB, a different committee board looking at safety and we will do what we

Dr. Towfigh (00:50:12):
Need to do. Yeah. The discussion that I have with my female patients about watchful waiting is, like you mentioned, there’s no trial including women of any substance looking at this information. We only have the maleed information. And the reason why UpToDate we have had no interest in it is because everyone’s afraid about missing a femoral hernia. And that’s the only really deadly hernia that we have. It’s a 5% death rate. If it shows up to the emergency room with an acute femoral hernia, it’s a 5% death rate. That’s the highest death rate of any other hernia that we know about. So what I do is I have a discussion. Of course, there’s no evidence behind what I’m saying to them. And I say, okay. They’re like, “Well, do I really need this hernia repaired?” I said, “Well, I can’t answer that question, but you’re an intelligent person.

(00:51:12):
If you want to undergo watchful waiting, let’s at least rule out a femoral hernia.” So I have a great ultrasonographer that does great hernias, or I get an MRI. And I say, “Okay, there is no femoral hernia, so I feel more comfortable with you choosing a watchful waiting. Understanding that we don’t know how people get femoral hernias. I mean, does it just pop up one day? I don’t know.

(00:51:42):
Are you born with your femoral space being more open? We don’t know. Is it thinner patients? I don’t know that we know any of that. But at least I can tell you don’t have a femoral hernia. So the chances of you having any major problem with the ingual hernia we know from the male that is pretty low. So yeah, fine. Go on your African vacation and travel and get pregnant and everything that you like to do without really worrying. But that’s the most that I can say.

Dr. Blake (00:52:15):
And I think that’s how we all approach it right now. As long as it’s not a femoral, we’re all comfortable watchful waiting. So for this trial, if we exclude all women with femoral hernia, we’re never going to answer that question.

Dr. Towfigh (00:52:31):
Yes, that’s right.

Dr. Blake (00:52:32):
So I think we need to learn the natural history of a femoral hernia better. And so this trial will let us do that.

Dr. Towfigh (00:52:42):
So when I was a resident, there was no watchful waiting trial. Everyone got scheduled for surgery. A hundred percent of people that came with inguinal hernia were scheduled for surgery. Now, some of the patients probably didn’t follow up, but there was never this discussion that it’s safe to watch. Everyone was told, “What if you get strangulate? We have to fix your hernia. This is to prevent a complication and strangulation and incarceration,” not knowing that the risk is what, 0.2% per year. So I’m hopeful that something like that will also come out with the women’s because I feel like for women, I mean, first of all, we’re not even doing a good job of diagnosing the hernia, but let’s say it’s diagnosed. Everyone is pushed towards the laparoscopic repair, which I know is a great repair, but it implies general anesthesia and implies mesh. And people feel afraid to go outside of that guideline because what if you miss a femoral?

(00:53:51):
But then if there is no femoral, let’s say with preoperative imaging, is it still safe to do a repair and not protect the femoral space? I don’t know that we know that.

Dr. Blake (00:54:02):
Yeah, that’s a good question. I don’t know that we know that. It seems safe in men. We do it all the time. Lots of Lichtenstein’s in men. And I have had women where maybe they want a tummy tuck or some cosmetic approach and they have an inguinal, not a femoral. And I have done either an open tissue repair or a Lichtenstein for them because we’re already there. And I’ve ruled out a femoral with imaging and just by looking at them during the operation. So yeah, I’ve done that in women where I’ve done a Lichtenstein. I have not covered the femoral space.

Dr. Towfigh (00:54:40):
Yeah. Let’s say you did imaging and confirm there’s no femoral hernia at the time. Are they still at risk of having one in the future? I don’t know that we know that.

Dr. Blake (00:54:52):
I mean, probably, but I don’t know that it’s. I’m sure it could be less than 1% risk. I don’t know. Yeah. I don’t know.

Dr. Towfigh (00:55:00):
I don’t know. Fascinating. These are things that keep me awake at night.

Dr. Blake (00:55:05):
Same. Same here. Yes. Yep. That’s one of them. Can I tell you about one more real quick?

Dr. Towfigh (00:55:12):
Yeah.

Dr. Blake (00:55:13):
We are also going to start, this would be just a single arm prospective cohort study of prophylactic or opportunistic salpingectomy at the time. Oh,

Dr. Towfigh (00:55:26):
Yes.

Dr. Blake (00:55:28):
That’s

Dr. Towfigh (00:55:28):
An interesting topic. You want to explain why that’s interesting?

Dr. Blake (00:55:32):
Sure. Yeah. So back 20 years ago, if a woman was done having kids, we would tie their tubes. Now, if somebody wants to be done having kids, we recommend to take out the tubes because we have found that the tubes, the fallopian tubes have the cells that can lead to one of the ovarian cancers that’s most deadly. So ovarian cancer is hard to screen for. Normally once we find ovarian cancer, it can be stage four and have spread all over the abdomen. And we have found that the most aggressive form of ovarian cancer comes from fallopian tubes. So when we’re operating on women and they’re done having kids, or if they’re already postmenopausal and they’re not planning on, again, having kids, we recommend just to take out the tubes to decrease the risk of ovarian cancer. And it’s found to decrease ovarian cancer by 60 to 80%.

(00:56:32):
Yeah, it’s not a very common cancer, but it reduces the chances by a lot. I

Dr. Towfigh (00:56:39):
Mean, the thought is if you have a 60-year-old lady who needs some type of abdominal surgery, let’s say a hernia surgery, and you can reduce their risk of ovarian cancer without really affecting any other. I mean, it’s a low-risk procedure, right? That’s the issue. It’s not very hard to remove the fallopian tubes.

Dr. Blake (00:57:07):
Right. Yes, it’s very straightforward. It adds maybe five minutes to a procedure. It’s very low risk of injuring things around it. It’s very straightforward. So in terms of the risk of the operation, at this point, we’re not saying schedule a surgery just to get the tubes out, but if you’re already there, just take them out. That’s where we’re at. No one has done a large number high power study looking at feasibility and safety of taking out tubes.

Dr. Towfigh (00:57:42):
Why don’t we do that for gallbladder surgeries or appendix surgeries too while we’re in there for those operations? I’m sure more women get gallbladder surgeries than helping surgeries.

Dr. Blake (00:57:53):
We should, absolutely. For just realistically to run this study, I use the ACHQC database, and that’s an easy national database that I can run these trials for. So I’m going to just do it for hernias, but absolutely we should be doing these for bariatric surgeries, straightforward appendices, gallbladders really. We don’t want to do it emergently, and people need to have time to think about it and have a consent. Yeah,

Dr. Towfigh (00:58:23):
Yeah, yeah. Elective. Elective surgeries.

Dr. Blake (00:58:26):
Yeah. Gallbladders, bariatric surgery. Absolutely.

Dr. Towfigh (00:58:29):
Oh, bariatric.That’s another good one because the obese are at higher risk for cancer.

Dr. Blake (00:58:34):
Yeah.

Dr. Towfigh (00:58:35):
Good one.

Dr. Blake (00:58:36):
Yeah, we’re excited about that. And then the last one’s looking at diastasis and small umbilical hernias in the setting of diastasis. Half the people get the diastasis repaired, half the people don’t, and we see what happens to the umbilical hernia. That’s

Dr. Towfigh (00:58:50):
A good one. That’s a good one. There’s a trend towards doing more of the diastasis closures. We

Dr. Blake (00:58:58):
Don’t quite understand diastasis. Yeah.

Dr. Towfigh (00:59:02):
It’s not a benign procedure.

Dr. Blake (00:59:03):
Yeah, correct. Yeah. People are getting –

Dr. Towfigh (00:59:07):
It can cause pain. Longer operation, it can cause pain and tearing, and some people will not look good.

Dr. Blake (00:59:15):
I agree.

Dr. Towfigh (00:59:20):
Very careful. Listen, I’m at Beverly Hills. A lot of tummy tucks that occur in this town. I have to be very careful who I offer a robotic diastasis closure to because.

Dr. Blake (00:59:33):
Yep. Same.

Dr. Towfigh (00:59:34):
Right? Yeah.

Dr. Blake (00:59:35):
Cosmetically, you, I think, typically have a better superior outcome if you’re doing tummy tucks with the diastasis compared to just a straightforward robotic or laparoscopic, just the way you pull the muscles together, either on the inside and it bulges out, or if you’re going to do the outside and you’re tightening things and making it in. So I agree. I do a lot of tummy tucks with diastasis. That’s my go-to.

Dr. Towfigh (00:59:58):
Yeah, love it. Well, my friend, it’s been good.

Dr. Blake (01:00:05):
It has been great. Thank you so much for having me. I really appreciate it. This has

Dr. Towfigh (01:00:10):
Been – I really enjoyed our hour together. Thanks so much for talking to me about all these topics.

Dr. Blake (01:00:15):
Yeah, right back at you. Yeah, I’m looking forward to seeing you at America’s Hernia Society next weekend.

Dr. Towfigh (01:00:22):
Yes, I will be tweeting about it. I like to live tweet during me. So for those of you who follow me on X at herniadoc, follow me because next week I’ll be in Denver, my not favorite city in the world. I will be at the hernia meeting and I’ll be sharing whatever I learned with you guys. And don’t forget to either subscribe to my podcast or to my YouTube channel at HerniaDoc, and you can watch this episode, all prior episodes of Hernia Talk Live. I think they’re just the best. I enjoy them. Many of you have told me that you watch it before you come see me in the office, so share with your friends. And again, Dr. Blake, thank you for your time and enjoy the rest of your evening.

Dr. Blake (01:01:13):
Thank you so much.

Dr. Towfigh (01:01:14):
Appreciate it. Thanks so much. Take care. Bye everyone. Bye.