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Speaker 1 (00:00:11):
Hello everyone, this is Dr. Towfigh. Welcome to Hernia Talk Live. I am your weekly host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist. Thanks to everyone who’s joining us as a Facebook Live at Dr. Towfigh. Many of you also follow me on Twitter and Instagram at Hernia doc and as always you can watch this and all prior hernia talk episodes. I think we’re up to 139 on my YouTube channel at Hernia Doc. I’m super happy to reconnect with a very good friend of mine for today’s Hernia Talk Live session, Dr. Luciana Guimarães. And I was recently in Brazil, as you know, for the International Hernia Collaboration and she was one of our wonderful hosts there. And I would like to very much welcome you Luciana.
Speaker 2 (00:01:07):
Hello
Speaker 1 (00:01:08):
Hernia Talk.
Speaker 2 (00:01:11):
It’s a pleasure to be here. I’d like to thank you for inviting me and I wish you can talk a lot about this subject that I love. Really love this.
Speaker 1 (00:01:22):
Yes. So Luciana is very unique because first of all, she’s our first Brazilian guest. So welcome for that. I learned a couple little words while I was in your beautiful country in Rio de Janeiro, which I love by the way. I loved that city. What a beautiful city. And you are all just wonderful. So bom dia and welcome. And actually for you would be, boa noite.
Speaker 2 (00:02:01):
Boa noite. Yeah, that’s it.
Speaker 1 (00:02:03):
Thank you. Because it’s what time is it now? 8:30 at night?
Speaker 2 (00:02:08):
Yeah.
Speaker 1 (00:02:09):
And you just came back early for this session? Yes. Otherwise you would still be in the hospital working hard?
Speaker 2 (00:02:16):
Yeah, of course. Oh my lord. I would be there. But a patient has was a lot of hungry and she ate.
Speaker 1 (00:02:24):
Oh she ate. So you had to cancel surgery?
Speaker 2 (00:02:27):
Yeah, tomorrow. Tomorrow will be her time.
Speaker 1 (00:02:30):
Oh my Lord. So you come from a family of doctors?
Speaker 2 (00:02:35):
Yeah.
Speaker 1 (00:02:35):
Yeah. Your father is a surgeon, is that correct?
Speaker 2 (00:02:37):
My father. Oh, my father is a surgeon. I have two, a sister and a brother. I am the middle and they are doctors too. Wow. But not surgeons
Speaker 1 (00:02:48):
But not But you followed your father’s Yeah. Footsteps. And you practiced together.
Speaker 2 (00:02:54):
Yeah, we practiced together. The first surgery that I helped with him was a hernia and I said No, this abdominal wall want closed. I was very, very scared cause I was sure that we would not close and in the end when we could close that. God like a magic.
Speaker 1 (00:03:18):
It’s like magic. Yeah.
Speaker 2 (00:03:19):
Yeah. Cause her neck is not too close. Just too close. Yeah,
Speaker 1 (00:03:24):
That’s right. We don’t just close, we need
Speaker 2 (00:03:25):
To take, it’s too close.
Speaker 1 (00:03:27):
Very true. So what’s unique with you in your country of Brazil, which is a very, very, very large country, is the amount of laparoscopic surgery that you do as part of your practice, especially for hernia surgery. We had a wonderful dinner where I got to meet so many women’s surgeons in Brazil and they were talking to me about the ability to do laparoscopic surgery and integrate laparoscopy into their daily regimen. And they said in their portion of Brazil, I don’t remember each individual, which city they were from, but they were doing over 80% of the gallbladder surgeries were open and open. In United States it’s about 95% laparoscopic, maybe 5% open. And for hernias, especially inguinal hernias, they said over 90, 95% of the hernias they were doing was open United States. It’s almost 50 50. About half of them are done open, either half laparoscopic. But you prefer and are the only surgeon in your group that does laparoscopic for hernias. Is that right?
Speaker 2 (00:04:45):
Yeah, in my cereal I think I am the only one.
Speaker 1 (00:04:48):
Only one?
Speaker 2 (00:04:50):
Yeah. Maybe one or two. But people prefer to make it a conventional way. Why that? I think it happens. Cause that
Speaker 1 (00:05:03):
Things, is it cost or technique?
Speaker 2 (00:05:05):
No technique. It’s just a hurdle. Yeah. Oh yeah. Hernia is the surgery that the resident will make. And the people don’t think that’s important to improve hernia surgery? No, it’s just a hernia. You make that in 10 minutes. You don’t need the monitor. Monitor the lap cough. It’s not necessary. It’s too fast. But we don’t need to say how important in how do better for the patient.
Speaker 1 (00:05:42):
Yes. Well that’s very interesting. So they feel that’s unnecessary to add extra technology
Speaker 2 (00:05:49):
To
Speaker 1 (00:05:50):
A hernia. It’s just a hernia. It’s a quick operation. Yeah. The resident can do it and
Speaker 2 (00:05:57):
The surgeon think that, oh, I can’t want to make a pro gastrectomy. But what about hernia?
Speaker 1 (00:06:05):
Yeah.
Speaker 2 (00:06:08):
And I must saying the it mean, what does it mean? It’s very serious. Yeah. Cause the, it’s the most common wellness that we’ll treat in our office.
Speaker 1 (00:06:19):
Hernia. Most common treatment. Yeah. The number one elective operation. Yeah.
Speaker 2 (00:06:24):
When you make any surgery you are passing from abdominal wall.
Speaker 1 (00:06:30):
Yeah.
Speaker 2 (00:06:31):
And we need to respect that.
Speaker 1 (00:06:33):
That’s very, very true.
Speaker 2 (00:06:35):
Yeah,
Speaker 1 (00:06:35):
Very good point. It’s very interesting you say this because when I was a resident it was a very similar discussion. Yes. Just a hernia. When I was a second year resident, my role was to take the first year resident through an inguinal hernia. And I hope I did well but for sure I wasn’t doing it as well as I’m doing it now. And at that time also laparoscopy was becoming in, being studied and yeah, they were saying that why do we need to do this laparoscopically when I can do just as good a repair open. So what is your explanation? Why do you offer laparoscopic inguinal hernias
Speaker 2 (00:07:24):
For the patient? Cause it’s better talking about pain recurrence. And when I, let me say something before that. Yes. When, when I saw a surgeon in hernia, the surgeon said, told to me you need to study before go. And I studied a lot about that anatomy. Yes. When I arrived at them, the surgery was laparoscopic And he asked me, what is it? I didn’t know. What is it? I didn’t know.
Speaker 1 (00:08:04):
Anatomy is complicated.
Speaker 2 (00:08:06):
Yeah. That’s the point. Yes. Surgeon looks like another anatomy.
Speaker 1 (00:08:12):
Yeah. The whole anatomy
Speaker 2 (00:08:13):
Is, and there is no surgeon that changes a lot when we are [inaudible].
Speaker 1 (00:08:18):
That’s true.
Speaker 2 (00:08:20):
And I didn’t know anything about that. And he said me, so you should stay home and study. I went to the anatomic in my medicine school and started to study in Paris there. And I made a research, I published, that was my first work that I published and my first publication and it was very good to me. So I stayed in love with Inguinal regional. And so that was when discovered that we need to study a modern anatomy. When you’re talking about abdominal wall in laparoscopy and open, they’re very different. Yeah. Nerves, vessels, everything’s different.
Speaker 1 (00:09:17):
Bladder. Yeah.
Speaker 2 (00:09:19):
Yeah. And when a patient comes to me, I show him we have three kinds of surgery open A per and robotic, I don’t have robotic here, but I need to explain the patient what we have. And they understand in the end they will choose with me what is better for them. I like to talk, I like to show that where will be the Mesh, what we are planning to do, what kind of Mesh, why laparoscopic, why not open, why onlay, why Onlay? Everything. We need to explain that.
Speaker 1 (00:10:05):
Very interesting. And how is it that you learned laparoscopic hernia surgery during your training? Because I met a female surgeon who I now follow on Instagram because she’s so lovely. She entered enrolled in the army in order to learn laparoscopic surgery because that was the only way she would get access to laparoscopic instruments, technology and so on. So how is it that the program you in
Speaker 2 (00:10:40):
Residence?
Speaker 1 (00:10:41):
Yes.
Speaker 2 (00:10:42):
I think it’s not enough in my residence. And I feel comfortable to say that we had many laparoscopic surgery, many very bariatric, gastric, colectomy. But hernia…
Speaker 1 (00:11:03):
None.
Speaker 2 (00:11:05):
No. And when I back there where the hospital there was resident, my boss told me that, oh come back here to teach me to make her. But he knows, he knows. Of course he knows. But it is something that it was not so, so good. We have, I left the residence 20 years ago. So yes, it was a little bit more, it was more difficult that time. Yes. Now I think things are be getting better.
Speaker 1 (00:11:44):
Okay, good. That’s very, very good. So we picked today’s topic to not talk about anal hernias necessarily.
Speaker 2 (00:11:51):
Yeah.
Speaker 1 (00:11:52):
But to talk about diastasis recti because I’ve heard multiple talks by you both in Costa Rica and in Rio de Janeiro, Brazil. And also I’ve seen you, your publications and so on about diastasis recti and surgical options for that. So let’s focus a little bit about that. If there are any questions that we can help answer, we’ll try and focus on that. But if hernia questions come, we’ll answer that too, if that’s okay. Maybe first you can explain what is rectus diastasis or diastasis recti. It’s the same thing, but
Speaker 2 (00:12:34):
What is it? Yeah, I think when you have the borders of rectus muscles around two or 2.2 centimeters, we need to consider that is a diastasis.
Speaker 1 (00:12:48):
So it’s a separation, but
Speaker 2 (00:12:50):
Yeah, a separation. But when we need surgery, when we don’t need surgery, yeah. I think that’s the first point. Ok. Cause the fitness and physicals professionals, they have a lot of works in that. And sometimes we can find a solution without surgery. If you have a professional that understands about diastasis.
Speaker 1 (00:13:22):
Got it.
Speaker 2 (00:13:24):
Yeah. And maybe they begin for example, in pregnant before a woman have a baby and sometimes they can, I don’t think for example, we have to educate surgery for a diastasis two centimeters. Yeah. Before trying another, trying another solutions.
Speaker 1 (00:13:52):
Now diastasis recti can occur in men and women. Do
Speaker 2 (00:13:58):
You see men? Yeah. Yeah. It’s
Speaker 1 (00:14:01):
Very genetic.
Speaker 2 (00:14:01):
Men and women. Yeah. Why do you think about women? Because pregnancy.
Speaker 1 (00:14:09):
Pregnancy,
Speaker 2 (00:14:10):
Yeah. After have a baby, they usually have something, especially in the midline middle of ab
Speaker 1 (00:14:17):
Because the rectus muscles, which it’s your six pack. Yeah. Those spread apart as your belly increases in girth during pregnancy. And then genetically some people that doesn’t go back to the same way you were before pregnancy. I also see in men, and it seems that a lot of these men as they grow older, when they gain weight or some
Speaker 2 (00:14:46):
People yeah they get fat,
Speaker 1 (00:14:48):
They get Yeah. But some of them, you know, could just tell there’s some families, the men always have flat bellies even when they’re 70 years old, flat belly. Others, it’s more rounded.
Speaker 2 (00:15:01):
Yeah. I think it’s according to the body. To the body. Some people get fat but they won’t have a constitution. Genetic constitution that is better for their muscles.
Speaker 1 (00:15:15):
Now is it is for the men, is there a way to prevent diastasis if it’s genetic?
Speaker 2 (00:15:24):
Oh yeah. Yeah. We feel exercise. But I think it needs to begin very early. Very
Speaker 1 (00:15:32):
Early.
Speaker 2 (00:15:33):
Yeah. So you reforce your core muscles not on abdominals, Rives, for example, your transversesalis
Speaker 1 (00:15:40):
Transverse abdominal
Speaker 2 (00:15:44):
Important to get that core.
Speaker 1 (00:15:48):
Yes. That’s called the interval. It’s
Speaker 2 (00:15:50):
Not just make the size for this part. We need to work our core. For example, it’s important the way you get up from your bed.
Speaker 1 (00:16:04):
How should you get out of bed?
Speaker 2 (00:16:07):
You should turn roll to roll. Yeah. And help with your arms to use the lateral. But I, I’m sure it’s very difficult. Cause when we see we are already in the bathroom to take a shower and we don’t remember the way we did. But it is really possible if you have a physical education.
Speaker 1 (00:16:35):
Yes, very true.
Speaker 2 (00:16:37):
And it’s not easy to have, for example, patient who got a baby. Yes woman got a baby, or a man who make some surgery, use the binder. It’s not good. Cause when you use a binder, abdominal binder, you not improve your muscles to work, to back to work the way they need to.
Speaker 1 (00:17:02):
Got it. Yeah. So you don’t prefer that patients don’t rely on a binder after pregnancy or after an abdominal surgery.
Speaker 2 (00:17:18):
Yeah. And they always ask, can I buy a binder? No, no.
Speaker 1 (00:17:25):
We had a session with a great Pilates instructor, gyrotonics Gyro, Kinesis instructor couple years ago where we reviewed all of the transverses abdominis exercise. It’s so important.
Speaker 2 (00:17:38):
So important.
Speaker 1 (00:17:39):
Yeah. Okay. So let’s say you have a diastasis and it’s genetic. And one question is, can you please elaborate on non-surgical ways to treat it or manage it?
Speaker 2 (00:17:58):
I think the congenital diastasis is more difficult to work than after pregnancy for example. Okay. But if it is bigger than larger than five, six centimeters, I think we need we to think about a surgery especially have a hernia associated with that. Yeah. Cause with the ears it can occur another problem. Cause of that.
Speaker 1 (00:18:41):
Yeah. Let’s say it’s two and a half centimeters. You think exercise can
Speaker 2 (00:18:50):
Make look
Speaker 1 (00:18:51):
Smaller? I think,
Speaker 2 (00:18:52):
Yeah, I think so.
Speaker 1 (00:18:53):
It’s not a cure though.
Speaker 2 (00:18:56):
Cure. I think we can try. We have already publications of physiotherapy on the physical professionals that improve that.
Speaker 1 (00:19:08):
Yeah. Yeah. I’ve seen patients that have diastasis, it’s not wide. It’s maybe two and a half, maybe three centimeters. So just over an inch. And they’re very fit. And their complaint is, so if you look at them, they look flat. But if they do a sit up, you can see it bulge. Or if they do. And so these are people that are very fit, very proud of their flat belly. If they tuck their tummy in. But once they allow the abdominal muscle to kind of pooch out, then the diastasis shows. So you can’t cure it, but you can control it when it’s smaller with transverse abdominis strengthening,
Speaker 2 (00:19:59):
I think you can control it.
Speaker 1 (00:20:01):
Yeah.
Speaker 2 (00:20:02):
I have a patient, a woman today I think, I wouldn’t, wouldn’t indicate for her. She’s thin. She has a muscles, you see that, you see her rectus. And we had something like four centimeters. And when I corrected that, I didn’t like the cosmetic result. I am sure I’m not a plastic surgeon. Yeah. I explain it for the patient. But in that case, lemme see if you understand. It was very, very together and she lost a little bit about that aspect. And she liked that she don’t have diastasis anymore. But the cosmetic result is not as good as it was. Yes. I think before, if you see a picture before, it’s much better than
Speaker 1 (00:21:12):
Yes. I know what you’re talking about. There was a trend five years ago or something. You could see the models than models. They had this, it looked like a diastasis, but it’s an indentation of their midline. And that was,
Speaker 2 (00:21:31):
That’s considered very physiological.
Speaker 1 (00:21:33):
That was considered pretty. So some people in Los Angeles, they come and they get liposuction of their midline to give that indented look to augment the six pack to make it look prettier. But not everyone has that. So if you do a tummy tuck or some type of surgical plication or suturing of when you narrow it, you have to close that gap
Speaker 2 (00:22:00):
To close. And something that I realized we have to be careful with the suture. We don’t have to go very far from that border.
Speaker 1 (00:22:17):
Yes.
Speaker 2 (00:22:18):
Cause we can make this in muscles.
Speaker 1 (00:22:22):
So you becomes, it becomes, yes. You take the muscles
Speaker 2 (00:22:25):
Doesn’t looks like it’s just one.
Speaker 1 (00:22:27):
Looks like this. It’s like this.
Speaker 2 (00:22:29):
Yeah. It looks like that one.
Speaker 1 (00:22:31):
Instead of being like this, it’s like this.
Speaker 2 (00:22:34):
That’s it. So they lose. That’s why
Speaker 1 (00:22:35):
Definition in between. Yeah.
Speaker 2 (00:22:36):
That’s why things are changing. Now. Last week we had an appointment with plastic surgeons to connect general surgeon with plastic surgeons.
Speaker 1 (00:22:54):
Yes. To work
Speaker 2 (00:22:55):
In cosmetic way.
Speaker 1 (00:22:58):
Yeah.
Speaker 2 (00:22:58):
And
Speaker 1 (00:23:00):
Yeah,
Speaker 2 (00:23:01):
I think it’s a evolution.
Speaker 1 (00:23:04):
Yeah. Do you think people who have diastasis recti also have like hernias? Let me rephrase this. Don’t mean ventral hernias specifically The collagen disorder we see in inguinal hernias, is that also a collagen disorder when people have diastasis? Or are those two different problems?
Speaker 2 (00:23:29):
No sir. I didn’t understand you. Who has inguinal hernia? Will have diastasis.
Speaker 1 (00:23:34):
Yeah. Are they related? I don’t think so.
Speaker 2 (00:23:38):
Diastasis? I don’t think so. Yeah, I understand. I’ve never saw something. I’m not sure. Yeah. I’m not sure. Hernias, yes. Hernia. Pediatric hernia. But diastasis, I’m not sure.
Speaker 1 (00:23:53):
Yeah. Yeah. I agree. Have you heard of Julie Tupler?
Speaker 2 (00:23:59):
Julie Tupler?
Speaker 1 (00:24:00):
Julie Tupler? No. She’s a nurse and she came up with a tupler technique for diastasis control. Have you ever heard of that?
Speaker 2 (00:24:10):
No.
Speaker 1 (00:24:10):
So she has some courses online, which are mostly trans versus abdominus exercises. Oh
Speaker 2 (00:24:19):
Yes.
Speaker 1 (00:24:20):
And she also has a binder that is a crisscross binder to Yeah. Hold it. And she promotes exercise-induced improvements in diastasis. Do you think that that helps?
Speaker 2 (00:24:39):
Yeah. I think so. The patient that I prefer to uses surgical treatment that has a hernia with diastasis.
Speaker 1 (00:24:53):
Yeah. Hernia with diastasis is the best combination.
Speaker 2 (00:24:56):
Yeah. Why? Because the patient who has just the diastasis, he’s in his mind, the problem is cosmetic. He says that I don’t feel pain, I don’t feel anything. But it’s not so good. My abdominal wall isn’t so, so beautiful. This patient is not for me.
Speaker 1 (00:25:26):
Yeah. Send that to the
Speaker 2 (00:25:28):
Yeah. Yeah. This patient not for me. Yeah. But the one that has hernia and need to improve that I think I will help this patient.
Speaker 1 (00:25:39):
Maybe you can explain why the understanding of a hernia within a diastasis is an important differential to make. It’s important to understand if your hernia in the middle, mid abdomen, is it just a hernia or a hernia within a diastasis? Can you explain
Speaker 2 (00:25:59):
What Oh yeah. Cause diastasis is the most important factor to rec recurrence. Yes. The hernia. Yes. Yes. Why? If a patient has a diastasis and you make a hernia surgery only hernia surgery, he has a chance to recur that. Very high.
Speaker 1 (00:26:23):
Yeah.
Speaker 2 (00:26:24):
Very high. And we need to get a solution. That’s why the most surgeries that I made by diastasis with flour, laparoscopic, I use it Mesh. I have just two cases that I didn’t use Mesh.
Speaker 1 (00:26:43):
So that’s very interesting because what I find happens many times is they have a diastasis, then they need colon surgery, gallbladder surgery, maybe appendix surgery, something like that. And they use the maybe stomach surgery and they have an incision through the diastasis. But that surgeon is not aware of the fact that now they are in a diastasis, which is naturally a thinner area of the abdominal wall than the rest of the belly. So then they do a great surgery than they close. And that becomes a hernia.
Speaker 2 (00:27:26):
That’s it. All surgeons are passing by abdominal know
Speaker 1 (00:27:35):
This is true.
Speaker 2 (00:27:36):
Yeah. And they need to look with more careful to abdominal no wall. Yeah. That’s the problem. When you introduce a trocar, you are operating abdominal, no wall.
Speaker 1 (00:27:53):
Yes.
Speaker 2 (00:27:54):
And what do you do with that?
Speaker 1 (00:27:57):
Yeah. Well you have yeah,
Speaker 2 (00:28:01):
Gynecologist. Gynecologist too close abdominal, don’t we need to talk about that?
Speaker 1 (00:28:09):
Yes, you do. Laparoscopic or robotic, you laparoscopic diastasis closure. Correct.
Speaker 2 (00:28:22):
Yeah, yeah,
Speaker 1 (00:28:23):
Yeah. Maybe you can explain that because we have a question to follow up with that. That was submitted. But why don’t you first explain what that means.
Speaker 2 (00:28:35):
We have a publication and the surgery I think in, it’s very interesting cause in less than 10 years we have more downtown pubica publications. Yes. With different names. Yes. About the same surgery. Same
Speaker 1 (00:28:56):
Surgery.
Speaker 2 (00:28:57):
That is two to work only. Yes. To work in our [inaudible].
Speaker 1 (00:29:03):
Yes.
Speaker 2 (00:29:03):
And in less than 10. More than one higher.
Speaker 1 (00:29:07):
Yes. That’s true.
Speaker 2 (00:29:09):
That’s why it’s a very interesting subject. Everybody wants to know about that.
Speaker 1 (00:29:14):
But there seems to be a lot of attention on diastasis recti at our meetings recently.
Speaker 2 (00:29:20):
Yeah. Yes. Yeah. So what do I do? I think it’s very important to choose your patient. A patient that is too fat, patient that has a very big hernia, a recurrence about some hernia, a large scar with problem in skin. This patient’s not for this technique.
Speaker 1 (00:29:56):
Okay.
Speaker 2 (00:29:57):
I will call it by scholar
Speaker 1 (00:30:00):
Scola S what do I do? Yeah. Yeah.
Speaker 2 (00:30:03):
A patient who has diastasis gastric hernia and not very big hernias. Incisional hernias. No, this is not for this technique.
Speaker 1 (00:30:15):
Yes. So
Speaker 2 (00:30:16):
What do I do?
Speaker 1 (00:30:18):
Normal weight patient with a medium tolar. Medium size diastasis. Yes.
Speaker 2 (00:30:24):
What do I do? We start, start with three trocars above the pubes
Speaker 1 (00:30:34):
Pubic bone. And
Speaker 2 (00:30:35):
Then yeah, we start icing the space in dissecting.
Speaker 1 (00:30:43):
Dissecting it.
Speaker 2 (00:30:44):
Yeah. Yeah. I always use Cushing cushioning. Above. Above. No, below the sacrum.
Speaker 1 (00:30:56):
Yeah. You put a cushion to bring up to
Speaker 2 (00:30:58):
Reduce patients’ lower bowel. Yes. It’s easier. And it avoid my touch in things.
Speaker 1 (00:31:05):
The thighs. Yeah.
Speaker 2 (00:31:06):
Yeah. Okay. And the Tietze, sorry. And we begin section with the counter, normal one monopolar. And we can get that space first. Lateral and midline.
Speaker 1 (00:31:23):
This is space between the fat.
Speaker 2 (00:31:30):
Yeah. And the midline. I always go trying to find hernia. When I find a hernia, I always stop and close in that moment. See? Cause the ring will be in virtual. It’s easier to
Speaker 1 (00:31:51):
Me. I saw that 10. That
Speaker 2 (00:31:53):
Was very smart. And I closed all of them. I closed all of them. Yes. I don’t make just the suture in the midline. Cause I have ever had a case, it was a friend of mine, a doctor who had a plastic surgery. Surgery. And after suture she had, she has, yeah. An interal hernia. And it was very difficult. Oh yeah.
Speaker 1 (00:32:20):
Very interesting. Yes. That’s very rare. But of course it happens to a doctor.
Speaker 2 (00:32:24):
Yeah. Yeah.
Speaker 1 (00:32:26):
Okay.
Speaker 2 (00:32:27):
That’s it. And that’s what I do.
Speaker 1 (00:32:31):
Okay. So then
Speaker 2 (00:32:32):
I use barb suture
Speaker 1 (00:32:34):
Yes.
Speaker 2 (00:32:35):
To correct diastasis. And you do no absorbable,
Speaker 1 (00:32:38):
You run the suture from the top to the bottom.
Speaker 2 (00:32:42):
From the
Speaker 1 (00:32:43):
Oid, from just below the chest bone. The xiphoid all the way down
Speaker 2 (00:32:47):
The middle. Yeah, yeah, yeah. I use the first incision that I made to the first stroker to in the end of the suture. Yeah. I always use barb suture in non-absorbable
Speaker 1 (00:33:00):
Suture, non-absorbable. You do two layers.
Speaker 2 (00:33:05):
No, only one
Speaker 1 (00:33:07):
Layer. So you any hernias you close but, and then in addition you do one layer of the diastasis. Yeah.
Speaker 2 (00:33:15):
Closure. But if I don’t have a barb suture non-absorbable, I use a barb suture. SU suture. Yes. Absorbable. Absorbable. Okay. And then I use a suture unabsorbable
Speaker 1 (00:33:34):
Because that’s easier. Yeah.
Speaker 2 (00:33:35):
Yeah. Cause that’s easier to, that’s smart. I don’t need some bar to some bar to help me. I don’t need somebody to help me. And I go the second plan. It’s very easy.
Speaker 1 (00:33:47):
Well, you’re
Speaker 2 (00:33:47):
Smart. But if I have barb surgery, barb suture, that’s what I do. One plant.
Speaker 1 (00:33:54):
Yeah. The barb suture. For those of you who are interested, it’s kind of revolutionized suturing. Yeah. Especially laparoscopically. Because the suture stays where we put it. Yeah. Because it’s only, it allows one way suturing and it won’t retract the other way. Yeah. Very good. Okay. So those people, okay, the question that’s presented is how is what you are doing different than what a plastic surgeon does?
Speaker 2 (00:34:27):
Sorry? How
Speaker 1 (00:34:29):
Is your surgery sc? How is your SC surgery different than a plastic surgeon tummy tuck?
Speaker 2 (00:34:36):
Oh, it’s very different. Cause I don’t, don’t work in skin.
Speaker 1 (00:34:40):
The skin. Yeah.
Speaker 2 (00:34:41):
Yeah, that’s, that’s a very important question. Cause if a patient has a lot of skin and the aesthetic result with hisco, what be good?
Speaker 1 (00:34:56):
Yeah.
Speaker 2 (00:34:57):
Cause plastic surgical surgery will work with that excess of skin. And I won’t make that
Speaker 1 (00:35:06):
An abdominal plasty or tummy tuck is actually two operations. One is what you explained, which is the closure of this widening to tighten up the belly or plication of the diastasis. But in addition, it includes removal of excess skin. That’s the typical tummy tucker abdominal plasty. So do the plastic surgeons in Brazil do tummy tucks on people that don’t have extra skin? Do they offer it like men? a lot of the men don’t have extra skin, but they need the diastasis
Speaker 2 (00:35:42):
Repair. Yeah. But I think it these patients good for cola. Why not?
Speaker 1 (00:35:48):
Yes. Those are better for scola
Speaker 2 (00:35:49):
For sure. And now what we are working, we are working with plastic surgeons. We can make the suture and then they work in that skin with laser. Oh, a laser. Yes. Very technologist. And I think the future will be that. But with robotic suture, I think plastic will use robot in theirs. And they won’t need us anymore. Sorry, I’m not to too, just a minute. Are you listen to me. I am not. Listen to you. Just a moment. Just a minute. I’m not listening to you. No. I’ll begin again. Just a minute. Now why I am not listening to you. Just a minute.
Speaker 1 (00:39:16):
Can you hear me now?
Speaker 2 (00:39:18):
Yeah. I don’t know what happened.
Speaker 1 (00:39:26):
No, it was a problem with my, for some reason my microphone was Okay.
Speaker 2 (00:39:31):
Fancy. So you were talking about the suture.
Speaker 1 (00:39:35):
Yes. Well what I was saying is that in Beverly Hills we tend not to have plastic surgeons that do much laparoscopy or robotic surgery. And they rely on us general surgeons to do that. So in patients that have a diastasis, that’s that’s small, not very wide. Because I think those should be done by plastic surgeons and they don’t have extra skin. That’s the perfect situation for
Speaker 2 (00:40:03):
The
Speaker 1 (00:40:03):
Topical robotic situation.
Speaker 2 (00:40:06):
I think. So I think that patient is ideal to this technique. And man, I think man skin, I am a woman. I don’t know if I should say that, but I prefer mens, A man skin looks like be more or less skin. They back.
Speaker 1 (00:40:38):
Yeah.
Speaker 2 (00:40:39):
To and the result is much better.
Speaker 1 (00:40:43):
I agree. So you are talking about closing the top layer of the muscle and really thin people can have the problem of the skin bunching up or the muscle not being overly sown. What do you think about sewing underneath from behind the muscle?
Speaker 2 (00:41:08):
Behind,
Speaker 1 (00:41:09):
Yeah. Posterior.
Speaker 2 (00:41:12):
Posterior practice. Oh yeah. Yeah. No, I think it’s a very good choice. Yeah. I think it’s a good choice. But I think this surgery is much better with the robotic robotically.
Speaker 1 (00:41:27):
Robotically. Yeah. Well easy
Speaker 2 (00:41:28):
Surgery cause it’s very difficult for the surgeon in the other day. Patients very good. And you are fire, you can smell your body. Yeah. Yeah. And for example, I’ve ever used the made the two surgeries,
Speaker 1 (00:41:50):
Two hybrid surgeries. Yeah. Yeah.
Speaker 2 (00:41:52):
Oh really? That stays very big below the, and I needed that. I did close it inside and to take out that mamma patient had a red two meshes only and I had to take that out. And the surgery, sometimes it’s very necessary. I think so. Yeah. Especially after three, four GNAs with that big diastasis. Yeah. And
Speaker 1 (00:42:28):
So here this patient has a diastasis two to three finger breaths. But it’s very fit and they have an umbilical hernia. So is that as a male, two to three finger breath diastasis with umbilical hernia. Would you think they should go to a plastic surgeon or have a laparoscopic or robotic repair?
Speaker 2 (00:42:50):
It depends on skin. I have one case, she went last week in my office and she’s very thin and she’s very, that patient’s very well. And she’s very thin. But she has a very good skin. She didn’t have that skin very, I don’t know how to say like a paper.
Speaker 1 (00:43:16):
No.
Speaker 2 (00:43:17):
Is a very good skin. Yeah. After surgery it was okay. And she didn’t have that excess in the midline.
Speaker 1 (00:43:28):
Yes. The punching.
Speaker 2 (00:43:29):
But I am sure I have a detail to tell you. Sometimes when you start to closing the diastasis, sometimes I take out the gas and take a look at the skin.
Speaker 1 (00:43:45):
Oh.
Speaker 2 (00:43:46):
If I think we have a lot of skin in the middle.
Speaker 1 (00:43:52):
Yes.
Speaker 2 (00:43:53):
I
Speaker 1 (00:43:55):
More, a lot of
Speaker 2 (00:43:56):
More for the lateral for that can divide,
Speaker 1 (00:44:00):
Move out. Yeah.
Speaker 2 (00:44:01):
Yeah. Sometimes until the aciar.
Speaker 1 (00:44:07):
Oh wow.
Speaker 2 (00:44:08):
Yeah.
Speaker 1 (00:44:08):
Wow. Yeah.
Speaker 2 (00:44:09):
And I learned it you if you plastic surgeons,
Speaker 1 (00:44:13):
Yes.
Speaker 2 (00:44:14):
They make a lot of the lateral and it don’t give any problem for the patient. And I think the skin gets more divided.
Speaker 1 (00:44:24):
Yeah. I think that’s something that I tell my patients, which is if it’s too wide of a dissect of a diastasis, the plastic surgeons do a much better job. First of all, they do a ti I think a tighter repair. But also because they do such a wide dissection on the fat off of the muscle and fascia and they get rid of excess skin that we don’t do and we don’t usually go lateral enough. Then cosmetically it looks better when the plastic surgeons do it. If there’s a skin issue. I don’t like the anterior lap. Laparoscopic plication too much because of the seroma risk. What do you think about that?
Speaker 2 (00:45:10):
God, I always say the patient, you will have seroma
Speaker 1 (00:45:16):
So hard to handle those.
Speaker 2 (00:45:17):
I don’t believe. I don’t believe, sorry. But I don’t believe Who says that makes the surgery don’t have seroma first.
Speaker 1 (00:45:27):
Yeah.
Speaker 2 (00:45:28):
First the most patients that looks for me to make this surgery, I don’t make you go for F for fitness center. Most of that patients not for me. That’s the first
Speaker 1 (00:45:48):
Point. They come to you, but you don’t operate on most patients that come to you for diastasis. Okay. Yeah.
Speaker 2 (00:45:54):
Second point, it’s impossible not to have serum first. We have a Mesh, we have gas, we have temperature. So the A posts will get and they will shock. The moleculars will shock. And you have serum. We have no way. Maybe we don’t need to make anything with that serum.
Speaker 1 (00:46:26):
Just don’t touch it.
Speaker 2 (00:46:28):
Yeah. I made ultrasonography in all my 39 first patients. All of them had serum.
Speaker 1 (00:46:39):
Yeah. Do you have any tricks?
Speaker 2 (00:46:41):
Maybe a little bit. One. I didn’t need to do anything but something that we’ll have. We have a space, we have a temperature. We have gas.
Speaker 1 (00:46:52):
Yeah. Fluid. Fluid.
Speaker 2 (00:46:54):
Ster
Speaker 1 (00:46:55):
Fluid collects there. But do you have any tips to reduce it? Do you use a drain?
Speaker 2 (00:47:00):
Yeah, I use one drain. Just one drain. Yeah. And I take that out with 10 days.
Speaker 1 (00:47:09):
Oh wow. 10 days. Why
Speaker 2 (00:47:12):
10 days? You see some publications saying that you can leave the drain seven to 10 days. Okay. Or when it will drain. 20 per day.
Speaker 1 (00:47:33):
20 milliliters per day.
Speaker 2 (00:47:35):
I never had a patient that has drained that in a four days, which drain? Oh, it’s drain just 10. I have never seen that.
Speaker 1 (00:47:53):
Yes.
Speaker 2 (00:47:54):
When I take the drain, when take out the drain, it’s still draining a lot. A hundred. But I need to take that out. I don’t stay with that drain.
Speaker 1 (00:48:06):
Well the plastic surgeons taught me, if you leave a little bit of fat on the fascia, you get less drainage. Yeah. Because that there’s lymphatics in that fat. So if you don’t disrupt that, you don’t want a beautiful nocia. You want a little bit of fat on the fat just a little bit. And that reduces your C rate. I don’t know.
Speaker 2 (00:48:32):
Yeah. I think we need to listen to them. Cause they are very smart. With the C
Speaker 1 (00:48:40):
Question that’s being asked, does laparoscopic surgery make you more likely to have diastasis
Speaker 2 (00:48:51):
Make more? Sorry,
Speaker 1 (00:48:52):
Diastasis. Does the gas from laparoscopic surgery make you more likely to have a diastasis?
Speaker 2 (00:49:01):
Oh, if it, I didn’t understand the question.
Speaker 1 (00:49:05):
When you put the gas in general, if any laparoscopic. Yeah. Let’s say lap laparoscopic appendix surgery, does that make you more likely to have a diastasis?
Speaker 2 (00:49:18):
No. No. No. No. I don’t think so.
Speaker 1 (00:49:20):
I don’t think so either. Yeah. No, don’t think so. And then what do you think about, so here’s another question about laparoscopic appendectomy causing an umbilical hernia. But oftentimes we remove the specimen from the belly button, like the appendix comes out through the belly button. And if you have a diastasis, then you’re more likely to get an umbilical hernia repair. I’m sorry, umbilical hernia. If you have a diastasis and you have a laparoscopic appendix surgery and they take out the appendix from your belly button and you’re higher risk for hernia there because you already had a diastasis, that’s probably what happens.
Speaker 2 (00:50:00):
Yeah.
Speaker 1 (00:50:01):
Yeah. Can you talk about obesity and diastasis?
Speaker 2 (00:50:06):
Oh yeah. Obese works like a pre. If you are obese, you of course our muscles won’t stand that for a long time.
Speaker 1 (00:50:19):
Yes.
Speaker 2 (00:50:21):
And I don’t know what the question wants know, but if I have already made this surgery in obese, not ob, but a little bit fat, I think this surgery is not good for patients that are very thin and not too fat.
Speaker 1 (00:50:41):
Yes. Yes. Yeah.
Speaker 2 (00:50:43):
I think the middle. Yeah. It’s the better. It’s the best choice. But OB, obesity, it’s of course it increased the chance to have a diastasis.
Speaker 1 (00:50:56):
Yes, absolutely. It’s one of the risk factors. Especially if you have a genetic predisposition towards it too. Yeah. Yeah. Are there any indications to close the diastasis? A diastasis in a male with no symptoms?
Speaker 2 (00:51:16):
That’s a good question. It’s not too big. For example, less than four centimeters and no symptoms. I think, no, I think we can try to work with the score not to reduce the diastasis. Maybe we won’t reduce, but we can reduce the problem that it can cause.
Speaker 1 (00:51:46):
Yeah. And reduced. Yeah. Yeah. Yeah. So if someone has a diastasis, sorry, someone is obese and gets a diastasis will lose. Here’s, here’s a question for you from one of our audience. Is losing weight, will that make the diastasis smaller?
Speaker 2 (00:52:13):
Yeah, I think it want maybe a little bit.
Speaker 1 (00:52:18):
Yeah. Not so much that the damage is done. Yeah.
Speaker 2 (00:52:20):
Not so much this patient. I think it’s good to two. He will be okay for surgery after lose
Speaker 1 (00:52:30):
Five after losing the weight. Yeah.
Speaker 2 (00:52:33):
Can you talk about
Speaker 1 (00:52:37):
Diastasis and back problems?
Speaker 2 (00:52:41):
Sorry, I didn’t understand. Back problems.
Speaker 1 (00:52:43):
Yeah. Back pain, lower back pain.
Speaker 2 (00:52:48):
Oh yeah, I, that’s what I talked about. The core.
Speaker 1 (00:52:54):
Yes.
Speaker 2 (00:52:55):
If we need rectos of abdominal work together, both of them. Because all of our muscles depends on that.
Speaker 1 (00:53:13):
Yes.
Speaker 2 (00:53:14):
And we can’t have a good work of our all core if we don’t have that abdominal wall working together because we need the strong back and the front to work together. If one of them are like, this one will suffer.
Speaker 1 (00:53:35):
Yes.
Speaker 2 (00:53:36):
So we need that integrity.
Speaker 1 (00:53:40):
Yes. a lot of women with very wide diastasis due to pregnancy, have back issues and they cannot support their back because they don’t have the abdominal wall function. And also people with hernias,
Speaker 2 (00:54:00):
Nels.
Speaker 1 (00:54:02):
Yeah. And the people with hernias have back problems too.
Speaker 2 (00:54:08):
Yeah.
Speaker 1 (00:54:08):
Yeah. Like have back pain. You fix their hernia, their back pain goes away.
Speaker 2 (00:54:14):
And I have to tell you something. Yeah. About the suture you were talking about when we make the suture.
Speaker 1 (00:54:21):
Yes.
Speaker 2 (00:54:23):
It’s very important. Something that I learned with plastic surgeons and when I made, I felt very much more comfortable not to suture in the same he, I’ll show you, you need to change the direction, need or not to cause any trauma to your facial like this. Not to use the point like this one, let me show you. Oh no, I can show you. You need to make a movement to get OBL glucose for not to cause any trauma to rectus fascia.
Speaker 1 (00:55:13):
Oh yes, yes, yes. You
Speaker 2 (00:55:15):
Get the needle and get that very strong. You cause a trauma and your suture may be not as good as it would be.
Speaker 1 (00:55:28):
Yes, that’s correct.
Speaker 2 (00:55:29):
You need to be careful with that.
Speaker 1 (00:55:33):
Good technique. Good technique. Yeah. I do a lot of the robotic posterior plication. So not the front because I hate dealing with seromas. But then I saw recurrences and we looked at our data and we found that if you have a hernia and a diastasis and you post do posterior plicate, you fix the hernia and you do the posterior plication. The hernia repair was a good hernia repair. It didn’t recur because the plication protected the hernia. Yeah. But the pation, the closure of that diastasis often fell apart, but it still protected the hernia. So I started using, using Mesh. I wasn’t using Mesh, but I started using Mesh and that seemed to help it. So for posterior you kind of have to use Mesh and I was doing two layers of closure, sometimes three. And then adding the Mesh. That seems to help it also. Yeah,
Speaker 2 (00:56:41):
I think it helps. Cause if we think diastasis, it’s not, it not so simple to treat. Oh, why? Cause it’s always very long.
Speaker 1 (00:56:56):
Very long. Yeah.
Speaker 2 (00:56:58):
Very long. It’s like an incisional hernia.
Speaker 1 (00:57:02):
Yeah. How do you make sure that you’re, the final product is the same from top to bottom, so you’re not too tight on the top or too tight on the bottom. How do you know that it’s smooth contour?
Speaker 2 (00:57:21):
Oh, the form of the body.
Speaker 1 (00:57:24):
Yes.
Speaker 2 (00:57:25):
In the middle. In umbilical. I always use it approach a little bit more and below.
Speaker 1 (00:57:37):
Oh really?
Speaker 2 (00:57:39):
Yeah. A little bit more
Speaker 1 (00:57:41):
In the middle.
Speaker 2 (00:57:43):
Yeah, in the middle. A little bit more. I learned it with plastic surgeons. Yeah. The books about plastic are very good to teach us that things
Speaker 1 (00:57:56):
Very interesting.
Speaker 2 (00:57:58):
A little bit more. And I think it’s not, we need to talk about umbilical fixation. It’s not so easy. It’s not so easy. Why first? It’s necessary to choose where it was. You need to mark our, I always use a suture to see where it was.
Speaker 1 (00:58:24):
Where it was. Yes.
Speaker 2 (00:58:26):
But when you fix pass the needle, I always pass the needle. I take a point and I take out the gas and look. Cause the skin, maybe it’s not good. You take it out and you make again, because it’s difficult to take in the right place.
Speaker 1 (00:58:55):
Yes. If you have
Speaker 2 (00:58:57):
Gas.
Speaker 1 (00:58:58):
Yes. Yeah. That’s true. I also teach by residents. When you recreate a belly button stock, don’t go straight down. Go a little bit towards the feet. Because if it goes straight down and the patient stands up, their stock tends to pull up. Yeah. But go a little bit towards the, and they stand. They have a perfect inning going straight back.
Speaker 2 (00:59:25):
Yeah. And then stay like that.
Speaker 1 (00:59:28):
Yes, exactly. Yes, yes, yes.
Speaker 2 (00:59:35):
Exactly that. We need to pay attention to that. Cause women, the first thing they will look in the mirror is the
Speaker 1 (00:59:42):
Belly button. It has to be in the middle and it has to be beautiful.
Speaker 2 (00:59:48):
Beautiful. Not crying.
Speaker 1 (00:59:49):
Yeah, not crying. Not sad. Luciana, this was a amazing hour. I had so much fun and I learned so much from you.
Speaker 2 (01:00:01):
Oh, it’s very good. I am so happy to be here with you. And I always learn a lot of you. That’s thank That’s true. Thank you. That’s true.
Speaker 1 (01:00:11):
Yeah. I think we both love hernias and we both.
Speaker 2 (01:00:16):
Yeah. Yeah. You’ll find other Again. Thanks a lot, Andy. Who wants to talk to me? I’m here.
Speaker 1 (01:00:23):
I love it. Well, okay. That’s how we’re going to end it. This has been a great, okay, great hour. Thank you so much for your time. Thank you. You back to your family. And my
Speaker 2 (01:00:35):
Pleasure.
Speaker 1 (01:00:36):
Blessed and thank you everyone for joining me on Hernia. Talk Live. This was another great episode where we talked with Dr. Guimarães from near Rio de Janeiro in Brazil. I hope to visit you in your office one day and see all the great stuff that you do there. Thank you. Everyone. Don’t forget, go to my YouTube channel at Hernia doc to watch this in all previous episodes, and I will join you again next week for another great guest. Enjoy.
