211. First Hernia Surgery Couple

This week, the topic of discussion was: 

• Hernia Surgeon
• Brazil
• Laparoscopic Surgery
• Robotic Surgery
• Public Health System
• Lichtenstein Repair

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.

Guests: Dr Natàlia Pascotini and Dr Paulo Fogaça de Barros of Brazil

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

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Transcript

Dr. Shirin Towfigh (00:00:10):
Okay. Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. My name is Dr. Shirin Towfigh. I’m your hernia surgery specialist. And boy do we have a treat. We have our first ever hernia couple. Dr Natàlia Pascotini and Dr Paulo Fogaça de Barros are both hernia surgeons from Brazil. You can follow them and their journey through the hernia world on Instagram at hernia couple. Very cute. And I just want to say thank you and welcome to Hernia Talk Live.

Dr Natàlia Pascotini (00:00:48):
Thank you so much Dr. Towfigh. We are honored to be here with you today.

Dr. Shirin Towfigh (00:00:55):
Thank you. It’s a great

Dr Paulo Fogaça de Barros (00:00:57):
Opportunity for us.

Dr. Shirin Towfigh (00:00:59):
So I think I met Natalia first, right?

Dr Natàlia Pascotini (00:01:03):
Right.

Dr. Shirin Towfigh (00:01:04):
Yes. When I was in Brazil.

Dr Natàlia Pascotini (00:01:06):
Yeah. I think it was the first time that we met.

Dr. Shirin Towfigh (00:01:10):
First time. So as many of, we have an international hernia collaboration and one year we had our meeting in Rio de Janeiro and that was the first time that I met Natalia and many, many other Brazilian surgeons. But I specifically remember Natalia because she was young, she was female, we had a very nice female group. She’s beautiful and she has this amazing story that I learned from her I think when we were out to dinner, right?

Dr Natàlia Pascotini (00:01:42):
Yeah. We got out to dinner on a female dinner.

Dr. Shirin Towfigh (00:01:47):
We had a women in surgery dinner to kind of promote more activity and involvement in the society by female surgeons because as many of you know, the hernia surgery in general is a very male dominated specialty. And as the decades go by, we have more and more women that are involved in it, which is great. And now I see you’re a hernia couple, so I would love to learn more. I would like to spend this next hour. We have a great audience of patients, very intelligent patients that ask a lot of really great questions. So I will feed those to you. But in the meantime, I’m just very curious to know more about your life, your practice, your specialty medical care in Brazil. So what city are you in currently?

Dr Paulo Fogaça de Barros (00:02:48):
No, I and Natalia work in

Dr. Shirin Towfigh (00:02:52):
Sao Paulo. Sao Paulo and I’m in Los Angeles. The city has a little over 3 million people. It’s a huge city. It’s considered a big city, but Sao Paulo, which is the capital of Brazil, has how many people

Dr Paulo Fogaça de Barros (00:03:07):
At Sao Paulo? There are in this moment 20 million peoples and Sao Paulo, 25, 20 6 million peoples in other cities is very, very close to Sao Paulo.

Dr. Shirin Towfigh (00:03:24):
Yeah. Oh my god, that is amazing.

Dr Natàlia Pascotini (00:03:27):
It’s huge.

Dr. Shirin Towfigh (00:03:29):
I can’t wait to come visit Sao Paulo.

Dr Natàlia Pascotini (00:03:31):
Yeah, it’s huge.

Dr. Shirin Towfigh (00:03:34):
So California, which is considered the largest state in the nation is 39 million people. The entire state.

Dr Paulo Fogaça de Barros (00:03:43):
You have

Dr. Shirin Towfigh (00:03:44):
25 million in just one, I guess the county around Sao Paulo. That’s amazing.

Dr Natàlia Pascotini (00:03:52):
Yeah.

Dr. Shirin Towfigh (00:03:53):
So Pao, you have a very different journey from medicine into hernia surgery than Natalia. And I’d love for you, I think yours is more traditional, like typical, is that correct? At least from a United American center.

Dr Paulo Fogaça de Barros (00:04:11):
My medical school is Sao Paulo. I finished my medical school in 2009. I finished my residence program in Sao Paulo in 2015 and the end for my practice, my residence period, I start to stood because I work together with Sergio Hall along the five, six years.

Dr. Shirin Towfigh (00:04:43):
Yeah, Sergio roll I have not yet had on as my guest. He is been very busy but he’s definitely on my list as one of the top surgeons in hernia in Brazil.

Dr Paulo Fogaça de Barros (00:04:54):
Yes, I studied hernia. I met you in 2019 in the Las Vegas because my first presentation

Dr. Shirin Towfigh (00:05:09):
I was sober. I swear I was sober but I can’t say this thing about my other friends,

Dr Paulo Fogaça de Barros (00:05:15):
I dunno. It’s about the case about the residents. Yes. You stay in the audience. I remember when I go out the podium I see her and you look me and it’s a great presentation very in the moment in 21 in the Brazilian hernia Congress. I met Natalia is first Congress

Dr Natàlia Pascotini (00:05:48):
And

Dr Paulo Fogaça de Barros (00:05:48):
What do you talk about this congress?

Dr Natàlia Pascotini (00:05:50):
So yeah, I had a little different graduation and stuff. So I am from the south of Brazil, so I am from a very tiny, tiny town in the south of Brazil. It’s not like Los Angeles or Sao Paulo. The city has 86,000 people. Wow. Yeah. So I did my graduation in medicine school and residency in cities nearby there. And then I moved to my hometown again and started my practice as a surgeon.

Dr. Shirin Towfigh (00:06:34):
And your father was also a physician, so that’s unique surgeon.

Dr Natàlia Pascotini (00:06:41):
Yeah, I think this is the main, it’s like I moved to my hometown. I think the reasons it was like my dad is a very skilled surgeon. He is retired right now, but at the time I lived there after my residency for six years. So I started my practice there. My father has an important role in guide me at the first complex cases, I was the very first male surgeon in my hometown.

Dr. Shirin Towfigh (00:07:26):
You were the first female surgeon in your hometown

Dr Natàlia Pascotini (00:07:30):
And

Dr. Shirin Towfigh (00:07:30):
Dad must have been so proud.

Speaker 4 (00:07:33):
And it’s a traditional town. I say that it’s a gacho town. I dunno if you heard about, but gacho is like the culture from my state hug grand and we have this, it’s like we can relate it to cowboys.

Dr. Shirin Towfigh (00:07:50):
Cowboys,

Dr Natàlia Pascotini (00:07:51):
Yes. So it’s people that work in the countryside.

(00:07:57):
So

(00:07:58):
It’s very tradition. So it was a little bit of shocking. Okay, have a female surgeon at first, but I nail it, thank God. And it was a pleasure to work there alongside my dad. He was and he’s an inspiration to me.

Dr. Shirin Towfigh (00:08:26):
That is so lovely. Luciana was a guest of mine, another great female surgeon in Brazil and you have some really great friends within the hernia community, so that’s very lucky. Now during your residency, how much hernia surgery did you do? Natalia.

Dr Natàlia Pascotini (00:08:46):
So my residency, it’s not like a fellowship of hernia residency in general surgery. So I did most surgery, hernia surgeries. It was open

Dr. Shirin Towfigh (00:08:59):
Surgery

Dr Natàlia Pascotini (00:09:00):
And the most part of it it was Lichtenstein repair. So I did a lot of that complex cases, not that much. I think during all my residency we did like 10 cases of complex hernia. Yeah, that’s fair enough. Not much.

Dr. Shirin Towfigh (00:09:22):
What about you Paolo? Did you get a lot of experience with hernias during your residency or no?

Dr Paulo Fogaça de Barros (00:09:28):
Yes, because in 12 the surgical coming to Santa CAA and change a view about the hernia,

Dr. Shirin Towfigh (00:09:41):
How one surgeon can change a residency experience, it’s so

Dr Paulo Fogaça de Barros (00:09:45):
Amazing. The view is a no complex case, is a normal hernia is not a big problem for general surgeries in Brazil surgery introduction, the hernia, the idea I remember is my first time I met the Dave de chain and my practice because the safe steps about the Lech stein but the Luciano nostalgia is, pardon me, in the resident period. He went in this time he will go to the Cleveland clinic for a research fellow and all the times call me, you need to ch because hernia is very nice. I believe in the moment of residence probably I work with the bariatric surgery, I like the topic, but in one or two years I chant my idea and I start to start just hernia.

Dr. Shirin Towfigh (00:10:53):
And now hernia surgery is so popular and bariatric surgery.

Dr Paulo Fogaça de Barros (00:10:57):
Yes, totally right.

Dr Natàlia Pascotini (00:11:00):
Yeah. I think it’s a great moment for us in the field of hernia. Yes.

Dr. Shirin Towfigh (00:11:06):
The story that I will never forget, Natalia is the one that you told me when I saw you in Rio de Janeiro that you enrolled in the

Dr Natàlia Pascotini (00:11:14):
Military

Dr. Shirin Towfigh (00:11:17):
On your own because that was the only way that you could get more experience with laparoscopic surgery. Is that accurate?

Dr Natàlia Pascotini (00:11:28):
Yeah.

Dr. Shirin Towfigh (00:11:28):
Amazing. Amazing.

Dr Natàlia Pascotini (00:11:29):
That is true. It is because that my practice in my hometown was we have here a public health system and in the public health system we don’t have all the resources that we want. So laparoscopic tools, it was not allowed to that patients. So I started think hernia, it’s not just open surgery, it’s way more and I have to study more. So I started to do courses and I had idea maybe the military, it’s a good idea to, because they had all the laparoscopic tools, they have resources, they have plenty of patients to take care of. So I started enter it in the military to improve my practice in laparoscopic. So it’s amazing. It was like I have good feelings about my time there and I met a lot of good people there and these experience make me improve, not personally only, but like a surgeon too

Dr. Shirin Towfigh (00:12:52):
That is dedication to enroll in the military, to advance your surgical skills. I will never forget that story

Dr Natàlia Pascotini (00:13:04):
Experience in doing alts or other stuff in the military that I think you add proficiency in a lot of stuff and you become better as a person. Yeah, it’s amazing.

Dr. Shirin Towfigh (00:13:22):
Very good. So fast forward, we now have the world’s first hernia couple. Yeah. So you moved up to Sao Paulo?

Dr Paulo Fogaça de Barros (00:13:33):
Yes.

Dr. Shirin Towfigh (00:13:34):
And do you practice together?

Dr Natàlia Pascotini (00:13:38):
Yeah.

Dr Paulo Fogaça de Barros (00:13:41):
Yes. It is not so easy for Natalia when you come to Sao Paulo she need to start in the zero level

Dr Natàlia Pascotini (00:13:55):
Here

Dr Paulo Fogaça de Barros (00:13:57):
Because in private practice is the patients come with the clinic, you need to construction your career along the time. Always nice, but the beginning is not so easy.

Dr Natàlia Pascotini (00:14:16):
It’s a little tough. We don’t have differently from United States, we are not okay. We are in private practice here it’s a little bit different from the United States, but here, even if you are, we don’t have a contract with the hospitals. It’s different from United States. So to build your practice it’s tough. Even I moved from a city that nobody knows me and now I am here in Sao Paulo. So at first year it was a little bit tough but now things are coming together and we work a lot of, we do surgeries together. I think that’s so cool. We were talking days before that we spend 60% of our time together. We share our family, our home and patients. And during the or we share experience too.

Dr Paulo Fogaça de Barros (00:15:19):
That is

Dr. Shirin Towfigh (00:15:19):
Tough

Dr Paulo Fogaça de Barros (00:15:21):
Is normal. The other physician help the surgeon.

Dr. Shirin Towfigh (00:15:26):
Okay.

Dr Paulo Fogaça de Barros (00:15:27):
It is normal to work together. For example, tomorrow and Natalia, I have one surgery and she helped me Friday. Natalia have one surgery and I help Natalia.

Dr. Shirin Towfigh (00:15:42):
Yeah, we have the same, we have surgeons who assist surgeons. Tomorrow I’m operating and my friend who’s a surgeon will be assisting me, which is very fun if you know the person and you like the person. Usually I don’t operate with practicing surgeons, I usually operate with residents and fellows. And so when I do get the chance to operate with someone highly skilled where I’m not leading them, they’re following me really well. I really enjoy that. It’s like a gift.

Dr Natàlia Pascotini (00:16:14):
Yeah,

Dr. Shirin Towfigh (00:16:15):
That is so cool. So what percentage of your practice is hernia based

Dr Paulo Fogaça de Barros (00:16:24):
Today? I operate just the hernia. I like the chronicle pain in my office. Some patients come about the chronicle pain and Sao Paulo is great because it’s a big city in Sao Paulo is more commonly robot precision. For example, in US I think is 5,000 robot platforms in US in Brazil. Brazil there are 150

Dr. Shirin Towfigh (00:16:59):
Less than

Dr Paulo Fogaça de Barros (00:16:59):
Robot platform.

Dr. Shirin Towfigh (00:17:01):
We have too much in the United States

Dr Paulo Fogaça de Barros (00:17:03):
Stay in the San Paulo, it is more easy to practice the robot platform.

Dr. Shirin Towfigh (00:17:07):
My hospital has I think 12 or 15 just my hospital.

Dr Paulo Fogaça de Barros (00:17:14):
Oh

Dr Natàlia Pascotini (00:17:14):
It’s a lot

Dr. Shirin Towfigh (00:17:14):
Too. The

Dr Paulo Fogaça de Barros (00:17:15):
Big here is Albert is in Albert is there are five robot platforms in the Uberized. But in other hospitals in private there’s a big hospitals, there are one or two robot platforms. It’s not so weak.

Dr. Shirin Towfigh (00:17:33):
And Natalia, how much of your practice is hernia?

Dr Natàlia Pascotini (00:17:37):
I think maybe, I think right now maybe 60 to 70%.

Speaker 4 (00:17:44):
It’s not

Dr Natàlia Pascotini (00:17:44):
Like a hundred percent like Paolo in the field of hernia. Long time, more time than me, but I’m trying to be in this field. This is what I want to do for my life. It’s like I put all my love, my heart medication and my time. So I think hernias can impact the quality of life in so many ways and we know fixing that and hearing the patients, examining the patients and knowing their histories, I think dunno it’s the most satisfying thing in the surgery field for me.

Dr. Shirin Towfigh (00:18:32):
I mean I would agree.

Dr Natàlia Pascotini (00:18:33):
Yeah,

Dr. Shirin Towfigh (00:18:34):
That’s very interesting because Paulo, you trained under Sergio role who was the first South American president of the American Hernia Society and just world renowned and very, very skilled surgeon and Natalia, you recently did a fellowship in the United States where you went and had experience with the greats of hernia surgery in the United States as well. So you should get all the patients with the hernias in your practice.

Dr Natàlia Pascotini (00:19:06):
God listen to you. In my

Dr Paulo Fogaça de Barros (00:19:07):
Opinion, the observership, it’s very important for us. It’s important because you break your way and you improve your product. I spent one time in Cleveland Clinic and other time I visited the David Chen

Speaker 4 (00:19:28):
And

Dr Paulo Fogaça de Barros (00:19:29):
I told Natalia, this opportunity is very important for your life and in your opinion the Natalia experience and the observership together, the Vera Chand your life

Dr. Shirin Towfigh (00:19:46):
And

Dr Paulo Fogaça de Barros (00:19:47):
Your mind.

Dr. Shirin Towfigh (00:19:48):
Vedra is amazing. Yeah. Dr. Augenstein was one of my earlier guests on this show and her episode is one of the most watched episodes.

Speaker 4 (00:19:58):
She

Dr. Shirin Towfigh (00:19:58):
Such an intelligent, bright, wise surgeon. In fact, I just saw a patient of hers, was it two days ago or something from North Carolina who she’s treating. I mean so complicated and she’s the best surgeon for that patient for sure.

Dr Natàlia Pascotini (00:20:18):
Yeah. It was an amazing experience too, catching together and shadowing her. So this was an opportunity that American Hernia Society gave me, applied to an observership and I stayed with Conder and Dr. Vera Augustine. So it was amazing. And after that, because of Paolo, because he talk lots about, lots about good things about David Chen and I met him in these hernia meetings, then I had opportunity to go to LA and shadowing him a lot of 10 days. Yeah, it was amazing. And I text you but we didn’t have time to met.

Dr. Shirin Towfigh (00:21:10):
I know we were talking back and forth and I think I was out of town or something had happened

Dr Natàlia Pascotini (00:21:15):
So

Dr. Shirin Towfigh (00:21:16):
I couldn’t see while you were here.

Dr Natàlia Pascotini (00:21:18):
Yeah.

Dr. Shirin Towfigh (00:21:19):
Great.

Dr Natàlia Pascotini (00:21:20):
Maybe in another opportunity.

Dr. Shirin Towfigh (00:21:22):
Why not? Why not? I need to come visit you guys.

Dr Natàlia Pascotini (00:21:25):
Oh please come and we’re going to make a good barbecue for you here in home. Oh my

Dr. Shirin Towfigh (00:21:33):
God.

Dr Natàlia Pascotini (00:21:33):
This how is our specialty?

Dr. Shirin Towfigh (00:21:35):
Amazing. So the question that I have is in my practice I see about 80% are complications. It could be something simple like a hernia recurrence or it could be mesh removal, chronic pain, et cetera. So is that a problem in Brazil too where a lot of patients have complications or no?

Speaker 4 (00:22:02):
Yeah. Yes. Yeah.

Dr. Shirin Towfigh (00:22:03):
Yes. And is this mesh related complications or is it just surgical complications

Dr Paulo Fogaça de Barros (00:22:12):
In this moment the complication is the recurrence. The recurrence is because the technique is not a normal recurrence. The statistic recurrence, the strategy is not so good for some surgeons clinical pain because 18% the patients, the population in Brazil, it’s public health.

Speaker 4 (00:22:39):
And

Dr Paulo Fogaça de Barros (00:22:40):
In public health is very normal to pr leaching stein performance

Dr. Shirin Towfigh (00:22:45):
Lichtenstein. So that’s open inguinal hernia pair with onlay mesh? Correct. Okay. I mean the problem with that is if you don’t do it correctly, you can injure the nerves or you can put the mesh in too tight or too loose or usually too tight. Yeah. What do you see as the problem technically causing the complications?

Dr Paulo Fogaça de Barros (00:23:10):
Yes, I receive some patients because of chronicle pain, the most patients is anterior procedure leaching stein procedure. I need to perform to remove the mesh and the practical triple and sometimes I need to fix other mesh, but it’s common in the office.

Dr Natàlia Pascotini (00:23:39):
I think that we have in Brazil, we don’t have fellowships in abdominal wall like United States. I think we are shifting to that, but I think it’s going to take a long time to achieve this that you in the United States have. Because I think every surgeon, they have to know how to do a proper lesion sign repair. This is for us here is the most common procedure, but there are a lot of variations and not all the surgeons that do a hernia surgery here are specialized know all the step-by-step of the technique. And I think that this is the one thing that we get problems with.

Dr. Shirin Towfigh (00:24:39):
So what do you think the, is the surgical problem, do they use a wrong size mesh? Do they put the stitches wrong? Do they not identify the nerves? What is the

Dr Natàlia Pascotini (00:24:49):
It’s all that mixed together. Like it’s small mesh, the first published article from Stein, so they picked that one and they stay in that phase like okay, see the mesh has to be bigger and I think that the stitches, it’s something that it happens a lot of time. They put a lot of stitches in the middle part of the fixation of the mesh and we have nerve entrapment there

Dr. Shirin Towfigh (00:25:27):
Laterally. They put stitches laterally.

Dr Natàlia Pascotini (00:25:30):
Yeah. Yeah.

Dr. Shirin Towfigh (00:25:32):
Line of medial overlap. I was looking this the best, the typical VS size should be around seven and a half by 15 centimeters. Right. You have to tailor it a little bit, but I just had a patient with one by four centimeter vsh, one so small it’s like this big, this much mesh was put in and of course the patient had a recurrence almost immediately. What was going through this? How do you even find one by four centimeter mesh? You have to buy cut. No,

Dr Natàlia Pascotini (00:26:13):
You have to cut this mesh. You don’t find one centimeter mesh. Yeah, I

Dr. Shirin Towfigh (00:26:18):
Think for a child it would be too. Oh my god. I

Dr Natàlia Pascotini (00:26:22):
Think surgeons are very creative and I think that maybe, oh, maybe I can put this. And I think the main problem it’s that the surgeons don’t follow their data so they don’t know that this patient records or had chronic pain or this stuff. Yeah,

Dr. Shirin Towfigh (00:26:45):
That’s true. Yeah. I have a question for you. One of our audience is a Brazilian jujitsu purple belt.

Dr Natàlia Pascotini (00:26:55):
Oh right.

Dr. Shirin Towfigh (00:26:58):
Brazilian jujitsu purple belt and they had to stop because they had so many hernia surgeries. So the question is do you see many Brazilian jujitsu related hernias and after repairing them, do your patients return back to jiujitsu training?

Dr Natàlia Pascotini (00:27:19):
Sure, sure. I think that this sports, we can say this sports hernia, but probably he has a real hernia.

Dr. Shirin Towfigh (00:27:29):
Regular hernia, yeah,

Dr Natàlia Pascotini (00:27:30):
Yeah. Regular hernia we can fix and they can do all the exercise and martial art. Paolo has experience on that bodybuilder patients and he does this kind of procedure and it’s totally okay to, I think the main proposal of a hernia surgery is that the patient can come back to do whatever they want.

Dr. Shirin Towfigh (00:28:06):
Yes, thank you. Yes. I love that because how many patients are worried or are told you can’t lift anything anymore in your life, you can’t travel, you can’t. And I’m thinking no, the whole purpose of the repair is to make sure to bring you back to your quality of life that made you happy. So we have to make sure we choose the right technique to get you there.

Dr Natàlia Pascotini (00:28:32):
Sure.

Dr. Shirin Towfigh (00:28:33):
This gave us specific, do you have a specific technique for the bodybuilders? Do you prefer laparoscopic or

Dr Paulo Fogaça de Barros (00:28:42):
The body building? The problem is umbilical hernia.

Dr. Shirin Towfigh (00:28:46):
It’s not

Dr Paulo Fogaça de Barros (00:28:47):
Big hernia. The problem is the

Dr. Shirin Towfigh (00:28:54):
Pressures

Dr Paulo Fogaça de Barros (00:28:54):
Of umbilical because he’s building is a competition. I performed a prepar Antonio mesh. I input preparatory mesh. I performed open, I use, I cut the skin

Dr. Shirin Towfigh (00:29:11):
Inside, underneath so they can’t see.

Dr Paulo Fogaça de Barros (00:29:15):
I close. This body building is very famous. He stay in the, how can I say? The last competition is more famous is

Dr. Shirin Towfigh (00:29:26):
Mr. Olympia. Yeah, Mr. O. Mr. Universe. Yeah.

Dr Paulo Fogaça de Barros (00:29:30):
He stay in the 10 top in the GI competition.

Dr. Shirin Towfigh (00:29:36):
Wow. Okay great. So you do a small incision inside the belly button. So when you stand and you’re prosing, you don’t see it and then you go through the defect pre peritoneal, you put a wider mesh than usual, is that right?

Dr Paulo Fogaça de Barros (00:29:54):
Yes.

Dr. Shirin Towfigh (00:29:55):
And then you just leave the mesh in there and you close the hole.

Dr Paulo Fogaça de Barros (00:29:59):
Yes.

Dr. Shirin Towfigh (00:30:00):
Permanent suture.

Dr Paulo Fogaça de Barros (00:30:02):
Permanent suture,

Dr. Shirin Towfigh (00:30:03):
Permanent suture.

Dr Paulo Fogaça de Barros (00:30:04):
But today I think it’s better observable suture because he don’t have a fat in the region. One month.

Dr. Shirin Towfigh (00:30:15):
See the knot

Dr Paulo Fogaça de Barros (00:30:16):
Before the surgery he

Dr. Shirin Towfigh (00:30:21):
Fell the knot? Yeah. Yes. Okay. Yeah. Okay. I can see that he says obrigado.

Dr Natàlia Pascotini (00:30:29):
Oh

Dr. Shirin Towfigh (00:30:31):
Yeah, we have good people watching. Okay. What tips? Oh interesting. So they said when you were observing or shadowing Dr. David Chen, what tips and skills did you observe from your shadowing?

Dr Natàlia Pascotini (00:30:48):
Oh, both. That was shadow Dr. David Chen.

Dr. Shirin Towfigh (00:30:52):
Yes,

Dr Natàlia Pascotini (00:30:53):
And for me, I think that one of the best thing, it’s not only the mesh repairs but how he treats patient with chronic pain.

Dr. Shirin Towfigh (00:31:07):
Oh, tell me more. I love it.

Dr Natàlia Pascotini (00:31:09):
Yeah, because this impact in all the spheres of the life of a patient,

(00:31:18):
Current

(00:31:18):
Pain, it’s difficult to leave. The patient doesn’t work while doesn’t have a relationship while because he is always in pain and I think pain attention in a truly knowing that this hurts

(00:31:41):
And

(00:31:42):
I know what you feel and I’m going to help you. I think this is the most important thing and and beyond that it has the repairs. So a lot of ectomies of these patients that treated with medication and with all the stuff, all the resources that they can have and it hasn’t worked. So I think now I perform better lesion sign and better and better all the practice because of these observership with Dr. David Chen and all the surgeons that I shadowed.

Dr. Shirin Towfigh (00:32:35):
That’s amazing.

Dr Natàlia Pascotini (00:32:36):
Yeah.

Dr. Shirin Towfigh (00:32:37):
Okay. Another question do of the bodybuilders, this is probably for pao. Do any of the bodybuilders ever get an inguinal hernia?

Dr Paulo Fogaça de Barros (00:32:48):
Inguinal hernia? In my practice a minimal invasive precision. The idea is a big mesh. It’s 15 to 10 is the small mesh for us.

Dr. Shirin Towfigh (00:33:02):
Yeah, 10 by

Dr Paulo Fogaça de Barros (00:33:02):

1. But the idea to input the mesh, this guy, it’s okay to return your prat in few days. The European Hernia Society to talk about the five days. I suggest one or two weeks because the mesh, it’s not comfortable for growing region in the beginning. The precision I prefer to return in two or three weeks. The normal active.

Dr. Shirin Towfigh (00:33:33):
Yeah. I have seen bodybuilders with angle hernias, but belly button tends to be the more common one. Yeah. Not as common in the groin, but yeah, I think laparoscopic surgery is better for the bodybuilders also. I would never put it on LA mesh for bodybuilder because they want to have the definition in their muscles. Yes.

Dr Natàlia Pascotini (00:34:01):
They don’t have fat. They are going to feel the mesh and only mesh I think we are not using very often. It’s like we use a lot of spaces. Al is our, I think the best region for me and I think for Paolo too,

(00:34:23):
To

(00:34:24):
Choose the way how the layer to put the mesh.

Dr Paulo Fogaça de Barros (00:34:29):
Yes.

Dr Natàlia Pascotini (00:34:30):
Only it’s not our preference.

Dr Paulo Fogaça de Barros (00:34:32):
I like the leaching time proceed because it’s possible to performance for local anesthesia.

Dr. Shirin Towfigh (00:34:40):
Yes, that’s right.

Dr Paulo Fogaça de Barros (00:34:41):
I knew my strategy is the patients have a problem for anesthesias heart problem. I performance only approach, but I prefer a minimal invasive approach for all the other patients.

Dr. Shirin Towfigh (00:34:58):
Yes. So for the inguinal, I think you need general anesthesia for the laparoscopic surgery and definitely you can do just sedation or something for the Lichtenstein. Now in Brazil they use a lot of epidural or spinal anesthesia.

Dr Paulo Fogaça de Barros (00:35:22):
It’s normal for general surgeries. But Natalia don’t use,

Dr Natàlia Pascotini (00:35:26):
We don’t use,

Dr Paulo Fogaça de Barros (00:35:28):
I just performed for local anesthesia and sedation.

Dr Natàlia Pascotini (00:35:31):
Yeah. We prefer to do local anesthesia or 10 blocks.

Dr. Shirin Towfigh (00:35:41):
So I see. So if the spinal anesthesia doesn’t replace general anesthesia, it replaces the sedation with the local anesthesia, right?

Dr Natàlia Pascotini (00:35:54):
Yeah. Yeah. It’s like we perform with mild stein, we perform with mild sedation and anesthesia. I agree. Yeah, I agree with that. To patients get like can walk and don’t have ary retention.

Dr. Shirin Towfigh (00:36:20):
Yeah, I agree. So much better

Dr Natàlia Pascotini (00:36:23):
For the pain too.

Dr Paulo Fogaça de Barros (00:36:24):
And the pain 80 hours to the anesthesia reabsorbable and the patient is possible to go to the house and don’t have a

Dr. Shirin Towfigh (00:36:33):
That’s true.

Dr Paulo Fogaça de Barros (00:36:35):
I need to talk about the patients the next day you

Dr Natàlia Pascotini (00:36:40):
They’re going to feel something,

Dr Paulo Fogaça de Barros (00:36:41):
Feel something.

Dr Natàlia Pascotini (00:36:43):
Yes, I know.

Dr Paulo Fogaça de Barros (00:36:45):
Yeah,

Dr. Shirin Towfigh (00:36:45):
Today you’ll be fine tomorrow morning. So sorry.

Dr Paulo Fogaça de Barros (00:36:48):
It’s normal. It’s normal. No problem.

Dr. Shirin Towfigh (00:36:51):
Yeah, this is true. This is true. One of your fans wrote a question, something that was discussed in the last course with the participation of Natalia and Paolo was physiotherapy to help these patients return to training safely. So when you have athletes, how do you give them advice about physiotherapy and training?

Dr Natàlia Pascotini (00:37:17):
So I think physiotherapy has an important role on coming back to the normal activities, especially with these patients that lift heavier weights, bodybuilders and stuff. But even for not professional athletes, I think physiotherapy it’s important to the core health

Dr Paulo Fogaça de Barros (00:37:45):
In

Dr Natàlia Pascotini (00:37:46):
General and to learn how to breathe, especially in complex cases like tar and things that are more complex than a hernia, inguinal hernia. I think that we have a lot of different kind of procedures. So patient with a small umo with diastasis and physiotherapy, it’s good for them to improve the core health before the surgery and after. And we have a patient with complex cases that we demand physiotherapy before to prepare for the surgery.

Dr Paulo Fogaça de Barros (00:38:35):
Yeah, the pulmonary,

Dr Natàlia Pascotini (00:38:36):
Yeah. Improve the

Dr Paulo Fogaça de Barros (00:38:37):
Function

Dr Natàlia Pascotini (00:38:39):
And improve the core health because after the surgery is going to be a little bit different. So patient has to be used to and have this core health, healthier core health.

Dr. Shirin Towfigh (00:38:56):
Interesting. Here’s a question that was submitted, hold on. Submitted by one of our guests. Let me one of our other audience members. So it says regarding differences, what are the differences regarding a hernia treatment between Brazil and the United States? In other words, now that you’ve been to both, did you take something from the US and now you’re using it in Brazil or did you actually have fun stuff and innovative stuff you do in Brazil that you brought to our friends in the US and they learned from you?

Dr Natàlia Pascotini (00:39:36):
So I think here Brazil is huge and we saw both realities. I came from a really tiny town that I didn’t have resources and I did mostly open surgeries. But in Sao Paulo we can compare to United States. We have the same resources.

Dr Paulo Fogaça de Barros (00:40:01):
J is a public health. In public health minimal invasive is completely different. The idea not normal, it’s open precision. It’s more common in the private prs. Some hospitals in Sao Paulo and other states for example, port is the same for the PRSs in the US there are robot platforms. There are many laparoscopic. And the medical device is the same.

Dr. Shirin Towfigh (00:40:32):
Someone is in Natalia’s hometown. Can they travel to Sao Paulo and get care by you through the public system?

Dr Natàlia Pascotini (00:40:44):
We are actually. We are now currently in the private

Dr. Shirin Towfigh (00:40:48):
Practice. Okay. Yeah.

Dr Natàlia Pascotini (00:40:49):
Private practice. So now we are not to be in a public system, you have to be inside a hospital that is public and it’s a kind of different, I cannot say, okay, I’m going to do this public. Got it, got it. I worked for

Dr. Shirin Towfigh (00:41:10):
Someone from the United States can come to see you for your care.

Dr Natàlia Pascotini (00:41:16):
Sure.

Dr. Shirin Towfigh (00:41:16):
Yeah.

Dr Natàlia Pascotini (00:41:18):
Paolo and I receive patients from lots of parts of Brazil and even from outside Brazil. Yes. That’s

Dr. Shirin Towfigh (00:41:28):
Good

Dr Paulo Fogaça de Barros (00:41:28):
To know. The Brazilian come to live in other countries and come to Sao Paulo for precision.

Dr. Shirin Towfigh (00:41:37):
A lot of what we call medical tourism where people travel to another country to get a care. So they go to Turkey to get their hair implants.

Dr Natàlia Pascotini (00:41:46):
Oh yeah, their hair done.

Dr. Shirin Towfigh (00:41:48):
Yeah. Yeah. So that’s really great to know that people can just travel to see you guys, particularly because you’re in the private sector and you exclusively do as much as possible hernia related surgery. And do you work at a hospital or a surgery or both?

Dr Natàlia Pascotini (00:42:16):
We work in the hospital and we have a private office that it’s outside. It’s not okay. Yeah. So we have both, but we operate only in hospitals. We don’t have a clinic to do that.

Dr. Shirin Towfigh (00:42:35):
Okay. You should open one if they can. It’s so much more efficient and I have my own team. It’s the same team every time. So it’s so efficient and the patients get the same exact type of treatment. I really like it. Okay. Another question, in addition to the choice between open and laparoscopic, what are the main cost drivers in cardiac treatment? So do patients have to pay for their mesh separately or how does it work there?

Dr Paulo Fogaça de Barros (00:43:11):
Minimalization are more expensive because the devices in Brazil, the OR is not very expensive. The price is staying the devices minimal. Eva, you need more devices. It is more expensive than precision open.

Dr Natàlia Pascotini (00:43:29):
Yeah. If you lose robotic platform, for example, the patient has to pay for the robotic platform here. So health insurance here doesn’t cover it. It covers if the patient has health insurance, it covers the hospital part, but it doesn’t cover the hospital and all the devices but not the robotic platforms for it.

Dr. Shirin Towfigh (00:43:58):
There’s an extra cost if you do the same, an extra cost.

Dr Natàlia Pascotini (00:44:01):
Yeah. So

Dr. Shirin Towfigh (00:44:02):
Interesting. But in the United States it’s not like that.

Dr Natàlia Pascotini (00:44:07):
Yeah, I think that’s why you have thousands and thousands of robotic platforms because all the patients have access

Dr. Shirin Towfigh (00:44:15):
To, well this is what’s interesting is the insurance company will pay you the same. Actually the insurance company will pay you less, pay the surgeon less for a laparoscopic or open surgery or robotic than for open surgery.

Dr Natàlia Pascotini (00:44:35):
Oh yeah.

Dr. Shirin Towfigh (00:44:36):
Because somewhere someone said, oh, I can do that so much faster laparoscopically and open takes longer. So open it. Actually they pay more a little bit than laparoscopic. Let me double check that actually because I think they changed it. It was so crazy. Yeah. So if you look at the units, I have it on my desk here. 4, 9 6 5 0 6 0.36 units 4 9, 5 0 5. Yeah, it’s still the same. It’s about one and a half units more for an open surgery than the same procedure. Laparoscopic or so they pay you more weird. So the surgeon gets paid less and then the hospital usually cannot charge more for laparoscopic or robotic.

Dr Natàlia Pascotini (00:45:30):
Oh, that’s crazy.

Dr. Shirin Towfigh (00:45:32):
So if you’re doing laparoscopic surgery, you’re probably more profitable for the hospital than robotic because the insurance will pay you the same. Usually they won’t pay you more because you’re using anything more expensive. Oh,

Dr Natàlia Pascotini (00:45:46):
Interesting.

Dr. Shirin Towfigh (00:45:47):
It makes no sense from economic standpoint for hospitals to get robots, right?

Dr Paulo Fogaça de Barros (00:45:56):
No,

Dr. Shirin Towfigh (00:45:56):
Economically it makes no sense.

Dr Natàlia Pascotini (00:45:58):
Yeah. Yeah. Here who pays is the patient has to pay. It’s not.

Dr Paulo Fogaça de Barros (00:46:06):
But in this moment in Sao Paulo is a great moment because when I use robot platforms, I just use the mesh and thete and my performs a laparoscopic approach. I need to fix, I need to throw car margin wise. This time the price is the same laparoscopic and robot procedure when the patient is private patients.

Dr. Shirin Towfigh (00:46:34):
It’s

Dr Paulo Fogaça de Barros (00:46:35):
Interesting. It’s completely different for you talk.

Dr. Shirin Towfigh (00:46:37):
Well, in my practice I charge the same because I don’t want the patient to think, oh, it’s going to be cheaper to do open versus, so I don’t want them to make that feeling. I need them to just choose whatever’s best for them. So for me, I charge the same whether it’s laparoscopic, open or robotic. If it’s the same diagnosis or procedure, I think the patient should make that decision. But the fact that the insurance companies pay less for more advanced surgery is crazy to me.

Dr Natàlia Pascotini (00:47:10):
Yeah. I think that’s why we

Dr. Shirin Towfigh (00:47:12):
Have insurance companies that are more and more profit every year and doctors get less and less and hospitals are shutting down.

Dr Natàlia Pascotini (00:47:20):
Yeah. I think world and wild is the same I think. Yeah, here it’s the same. Yeah.

Dr. Shirin Towfigh (00:47:26):
Another question, do you do diagnostic blocks prior to Neurectomy? When you choose to do the triple neurectomy, when you do the patients with chronic pain and do the patients get dilated innervated abdominal walls? I don’t know what that means. Oh, okay. So this is a question number one. When you see a patient with chronic pain, do you first in your office do nerve blocks before you submit to triple neurectomy? And the second question is when you do the triple neurectomy, do the patients get a weakness of their abdominal wall where it gets bulging?

Dr Paulo Fogaça de Barros (00:48:11):
For me it’s this step, the block, the nerves. It’s very important for understand the pain. I think this pain is a neuropathic pain. I performed a block, the patients improve the pain after the block.

(00:48:29):
These

(00:48:30):
Patients probably, I solved this problem when I performed the neurectomy. I don’t told my patients about the time, anesthesia time, for example, three days after the use, the local anesthesia,

(00:48:51):
The

(00:48:52):
Patient report, no pain, this patient, it’s not neuropathic pain, it’s all other cows. And the second is,

Dr Natàlia Pascotini (00:49:01):
Oh, okay. If the patient feels like B after triple,

Dr. Shirin Towfigh (00:49:06):
Triple, yeah.

Dr Natàlia Pascotini (00:49:08):
Yeah. I think it’s not very common because at first we started doing triple neurectomy very high in the abdomen and now we do differently. We perform hybrid procedures in the meantime because patient with pain, chronic pain most time are related with an open surgery. So we take off this mesh, we do the neurectomy at the, how can I say that? At an anterior and then go laparoscopic and do the other nerve. The

Dr Paulo Fogaça de Barros (00:50:04):
Genital

Dr Natàlia Pascotini (00:50:05):
Femoral, genital femoral nerve.

Dr Paulo Fogaça de Barros (00:50:05):
It’s more easy to minimally.

Dr Natàlia Pascotini (00:50:07):
Yeah, minimal invasive. So it’s not too high.

Dr Paulo Fogaça de Barros (00:50:11):
Yes, I saw my idea is the patients develop a chronical pain is a neuropath pain. I would like to perform anterior neuropath triple neurectomy, the nerves below the oblique stern oblique stern muco and the genital femoral, the patients don’t solve this pain. I performed the posterior triple. I cut the nerves below the lumbar when I cut this nerve, the ilio hypovascular and ilio inal in the quadrat lumbar. These patients develop A ing the region for INO regime.

Dr Natàlia Pascotini (00:51:00):
In most patients we can solve the neuropathic pain performing like the anterior neurectomy.

Dr. Shirin Towfigh (00:51:09):
Yeah. What has never been shown in textbooks is that ileal and ileal hypogastric nerve have a motor function that they serve the abdominal wall muscle. It was always groin pain, groin skin hypersensitivity and so on. So when we went from anterior triple neurectomy, which is the common triple neurectomy higher up to posterior triple neurectomy, we said, oh my god, these people are getting bulging. So what you’re doing is exactly right as much as possible stay anterior. So cut the nerve as far away from the spine as you can to reduce the risk of deprivation. So where the abdominal wall gets affected. And then even if you, so I personally am not a fan of any type of laparoscopic triple. I think that’s really when you get the injuries to the abdominal wall. But if you have to then do it as far away from the spine is possible because that’s your least likely to get the motor branches.

(00:52:26):
Right? Yeah.

(00:52:26):
Yeah. It’s a problem. It’s a problem. There’s no good treatment for that once that nerve is cut.

Dr Natàlia Pascotini (00:52:33):
Yeah.

Dr. Shirin Towfigh (00:52:34):
I’m trying to err more on using ablation therapy and it seems to be less damaging to the nerve than actually cutting it if it’s possible for the ones that are more possible like upstream. Okay. We have more questions. Okay. Are there situations in which, are there situations in which hernia associated pain spontaneously resolve leaving patients free to consider watchful waiting as an alternative to immediate surgery? In other words, if they go from no pain to pain, will they ever go back to no pain?

Dr Natàlia Pascotini (00:53:18):
Okay, so pain with hernia, right? Yes. Patient has a hernia, have pain and it solves like spontaneously, right?

Dr. Shirin Towfigh (00:53:32):
Yeah. Can the pain ever go away without surgery?

Dr Natàlia Pascotini (00:53:36):
Yeah, I agree. Yeah, I think it’s really possible, especially in males that we can do this watchful waiting strategy.

Dr Paulo Fogaça de Barros (00:53:50):
Yes. But it’s very important these patients come to the clinic and the physician exam, this patient and watchful wait is the idea for the physicians, not the patient.

Dr Natàlia Pascotini (00:54:04):
Yeah. Do a follow up like small hernia. Good point.

Dr Paulo Fogaça de Barros (00:54:08):
Good point. Yes. This is important. Very

Dr. Shirin Towfigh (00:54:11):
Good point.

Dr Paulo Fogaça de Barros (00:54:14):
Small hernias, the patients, a few symptoms it’s possible to watch for weight. I like this idea because the big problem for fix the inguinal region is the chronicle pain. What for weight? Probably the young peoples develop a pain along this what for weight this time and need to fix it. But the old patients probably is not necessary to fix it. Her it’s a great idea.

Dr Natàlia Pascotini (00:54:48):
But in female, I am a little bit worried about incarceration and I don’t feel that watchful waiting. It’s a good way to lead the hernia in female. Yeah.

Dr. Shirin Towfigh (00:55:08):
The University of Michigan group just got, I think that they get grant funding or they applied for grant funding to do a female watchful waiting trial. As you know, all the watchful waiting trials were male only.

Dr Paulo Fogaça de Barros (00:55:27):
Yeah, it’s not so easy because just 3%, the humans, the developer, I think the mans are 30%. It’s more easy to understand along the time is

Dr Natàlia Pascotini (00:55:42):
Easy, but if you want to advise Brazil, it’s more we have more women than men in the population in general, so

Dr. Shirin Towfigh (00:55:50):
Oh, interesting.

Dr Natàlia Pascotini (00:55:51):
Yeah. So 3% maybe it’s something

Dr. Shirin Towfigh (00:55:57):
Good number, a good number picture

Dr Natàlia Pascotini (00:55:58):
That it’s almost women.

Dr. Shirin Towfigh (00:56:01):
Yeah. I think based on my own practice where I see so many women with undiagnosed angulo hernias, their pain is, they say it’s in your head and they don’t say it’s from your hernia. So they’re discounted, not diagnosed. That number is probably a little bit higher, but certainly not as high as meds as far as we

(00:56:23):
Know.

(00:56:24):
I would say sometimes I see patients that see me because they had a hernia and they went to their medical doctor and they said, oh, you have a hernia, stop the gym, don’t do any exercise, et cetera. And the hernia actually gets worse.

Dr Natàlia Pascotini (00:56:39):
Yeah. This is so unfair. The patient,

Dr. Shirin Towfigh (00:56:42):
Yeah, now they have pain, they’ve gained weight. And I said, listen, go back to the gym. Do all your exercise, lose the weight. If you still have pain, I’ll fix you. But if the hernia gets smaller, actually you have better muscles and you have no pain, you’re done.

Dr Natàlia Pascotini (00:57:03):
And here it’s common when patient comes with us, they have our phone numbers. I love it. Personal phone numbers. So if the patient comes to us, they have the number and they’re okay, we are not sure if you are going to operate, we are going to do a watch void. If at some point you get worse on the pain or you have some problems, call me. And that works because patient feels that they are secure doing that and they have how to reach us.

Dr. Shirin Towfigh (00:57:44):
Yes. And here’s a question related to that, which is does a sedentary lifestyle give you higher risk for developing new or recurrent hernias? There’s one trial that showed, I think it was in Swedish women, those that exercise regularly had a lower risk of hernia than those that didn’t exercise.

Dr Natàlia Pascotini (00:58:09):
I think that the lifestyle in general, it’s more important than only the sedentary lives like

Dr Paulo Fogaça de Barros (00:58:18):
Diabetics, tobacco, obese patients,

Dr Natàlia Pascotini (00:58:22):
People that don’t eat properly. And I think hernia, it’s a multifactorial. So it’s not just doing exercise. I think it’s a way, this lifestyle that you have can impact on all your health, but hernias too.

Dr. Shirin Towfigh (00:58:45):
Yeah, I a hundred percent agree. So this is coming to the end of our wonderful hour. I told you it will go really quickly. I have so many more questions, but I’m going to have to do it in person next time for Americans or anyone else who’s watching in the audience, because I do have an international audience, if they want to see you for a consultation, how do they find you?

Dr Natàlia Pascotini (00:59:13):
Oh, first I think they can follow Hernia Couple. And we are now launching our, it’s hernia, Brazil with S, we spell it S here. So we are putting this on this website, all the information about not only our clinic, our office, but good data about hernia, all the kind of stuff, evidence-based information there. So even patients or surgeons that want more information about hernia can reach us. And I think maybe this week Hernia Brazil is going to be launched so they can follow us on Hernia Couple and they can get this website with this good information.

Dr. Shirin Towfigh (01:00:13):
Okay, I love it. And so that is how we’re going to end it. Follow Hernia couple at Hernia Couple on Instagram. Although Doctors Pascotini and Fogaça de Barros have their own Instagram and Twitter pages as well. I have my own, don’t forget to follow me on X and on Instagram at Hernia Doc. And for those of you that have been submitting your questions on Facebook, I appreciate you and know that this episode and all prior episodes are available on my YouTube channel at Hernia Doc. And if you like to watch or listen to podcasts like I do, you can do the same on any podcast at Hernia Talk Live. So thanks again you guys. I really appreciate it.

Dr Natàlia Pascotini (01:01:00):
Thank you much. Thank you so much. Weird to have you have with us.

Dr. Shirin Towfigh (01:01:06):
Thank you. Thank you. Okay, see you later. Bye-bye.

Dr Natàlia Pascotini (01:01:09):
See you. Bye-bye.

Dr Paulo Fogaça de Barros (01:01:10):
Bye-bye.