216. Hernia Surgery in Central America

This week, the topic of discussion was: 

• Costa Rica
• Mexico
• Guatemala
• Hernia Surgery 
• Laparoscopic Surgery 
• Robotic Surgery
• Mesh
• Ultrasound
• Mesh Fixation
• Chronic Pain

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.

Guest Panelist: Dr Kathy Cordero, Clinica HRN, Costa Rica

Topic: Hernia Surgery in Central America

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Transcript

Dr. Towfigh (00:00:11):
All right, everyone. Looks like we're live. Welcome to Hernia Talk Live. My name is Dr. Shirin Towfigh. I am your host for the almost weekly Hernia Talk Live podcast. Thank you everyone for joining me. As you know, you can find me here as many of you are on Facebook Live as well as you're joining me here from Zoom, but know that once this is completely recorded and we have all of your input from the live version, you can see all of this archived and shared with all your friends and family that you want. You can share it on YouTube and of course you can find me on Instagram and on Twitter or X. So thanks for joining me because today I have a really, really fantastic guest. She is an excellent friend of mine. Our guest today is Dr. Kathy Cordero. She's joining us. Well, we'll discuss where she's joining us from, but I'd just like to explain to you all, let me just be able to share.

(00:01:18):
Why can't I share here? There we are. Dr. Kathy Cordero, she is Costa Rican and she's a very good friend of mine. We met in the United States, but also in Costa Rica. We'll discuss that. And she is part of multiple different centers, the Clinica Biblica, I believe, and also the Clinica HRN, which is a hernia surgery clinic. We'll discuss all of that and more. You can follow that clinic at clinicahrn@facebook. And I'm just going to stop there and introduce you to my very good friend. I'm so happy to have you, Dr. Kathy Cordero. How are you?

Dr. Cordero (00:02:03):
Hey, Shirin. A pleasure to see you.

Dr. Towfigh (00:02:07):
Thank you so much for joining me. Thank you for having me. You have been such a great friend and such an intelligent surgeon. We have done such great work in Central America with our hernia education, mostly through the International Hernia Collaboration. And you were probably the strongest person advocate of these educational programs. And you're so well respected in the region. And I'm just so happy to have you on as a guest.

Dr. Cordero (00:02:39):
Thank you so much. It's been always a real pleasure. And I do appreciate how much you guys have encouraged me on all my projects. Some people said, "Oh my God, you're nuts." But you always believed in every single project that I had on my sleeve and you were always very, very supportive. The American Hernia Society, the International Hernia Collaboration, and taking top class knowledge and academic surgeons to third world countries, it has improved so much, at least in our area, because things have definitely changed for the better. There was a before and an after.

Dr. Towfigh (00:03:22):
Well, as you know, I'm in California, so we have a very close relationship with our friends immediately below our border, south of our border in Mexico. And then soon thereafter, we've gone to other countries as well. Costa Rica was our first Central American country that we came to visit for the educational program, and it was such a success thanks to you. But before we get into the details of that, why don't you please just tell our audience, which are mostly patients, how you got into surgery and what your plans are originally when you went into general surgery, and then what kind of practice you currently have?

Dr. Cordero (00:04:03):
Well, initially when I started medicine, I think I wanted pediatrics.

Dr. Towfigh (00:04:11):
Not me.

Dr. Cordero (00:04:12):
While my career, I was obsessed with pediatric surgery. So I ended up with a scholarship in Harvard where I did part of my internship, like half of it. And then I did an observership. I don't know if you know Patricia Donahoe.

Dr. Towfigh (00:04:28):
I do. Wow.

Dr. Cordero (00:04:30):
She has been the inspiration for me in my life.

Dr. Towfigh (00:04:33):
Amazing.

Dr. Cordero (00:04:34):
So she welcomed me in her service and she was a magnificent surgeon, academic, wonderful lady, mom, wife. And I was like, "Oh my God, I want to be like her." So I stayed there, but then pediatric surgery got a little bit tedious or I don't want to say boring, but it was repetitive. But I always loved the hernias and how you fixed them, how anatomic they were. But it was pretty much the same every day. I loved the cases with Dr. Donahoe. We had really complex renal cases like urology, which was her specialty. And they offered me to state that was 20 years ago to do the residency at MGH. And somehow -

Dr. Towfigh (00:05:23):
Mass General at Harvard, yeah.

Dr. Cordero (00:05:25):
Yeah. Somehow back then, they were not as proficient. Residents were not allowed to do as much.

Dr. Towfigh (00:05:35):
As your home country?

Dr. Cordero (00:05:37):
Even as senior residents because the liabilities, insurance and all that stuff. So I decided to go back home and do my residency because back home, my residents were pretty much in charge of everything. I was like, "I

Dr. Towfigh (00:05:54):
Want to

Dr. Cordero (00:05:54):
Do it all." So I came back, I did my residency and all that. And I always kept in close relationship with the American College of Surgeons as a fellow resident and et cetera. And then over the years, hernia surgery, when it has changed so much, it grew so much into me because any other procedure, surgery or field hasn't changed as much as hernia. In terms of techniques and also materials, everything that we use. Hernia has been a field that has been evolving so much that is like what we'd learn either in med school, residency. It's so different from what

Dr. Towfigh (00:06:39):
We're doing

Dr. Cordero (00:06:39):
Nowadays or what we should be doing nowadays.

(00:06:43):
So definitely it got to me. And then I met this wonderful family group of people through the American Hernia Society, the International Hernia Collaboration, where they just want to explore and broaden all the knowledge and bring it to everybody and teach and have these guidelines so we can all do and practice the same type of surgery. So it has been a wonderful journey. And that's how I ended up here in New York because I was offered a position in research because things have changed so much, techniques and materials that I was wondering, is this really the best thing we can do? Is this working for the patients? So I wanted to do real research and take some time. And I was two years at NYU doing so. And I got it off my chest. And now I'm between here and Costa Rica. So I go fly back and forth.

(00:07:45):
Where I have tenure at my home hospital, I've been there for over 20 years. And there's a lot of work because it's social service. It's like social security medicine.

Dr. Towfigh (00:07:57):
Fascinating. So you're currently in New York. And your hometown is where in Costa Rica?

Dr. Cordero (00:08:06):
It's a capital, San Jose.

Dr. Towfigh (00:08:08):
In San Jose where we were.

Dr. Cordero (00:08:09):
Where we work pretty

Dr. Towfigh (00:08:10):
Much. Yeah. Beautiful city. And you've been practicing as a general surgeon mostly the past 20 something years. And is your current practice hernia exclusive or also general surgery?

Dr. Cordero (00:08:23):
No, I do a lot of general surgery, trauma, heart surgery even if there's a need.

Dr. Towfigh (00:08:30):
Like what?

Dr. Cordero (00:08:32):
When I got back home after my two years of like. We don't say sabbatical, but it's like I got out those two years to do research. The first day I got back, I had a 17-year-old kid with a stab wound in his heart. I was not supposed to be around. Somehow I was there doing something else and I saw him and he was without an ounce of blood in his body. And I took him to the shock room and we could not even sedate him because he was going to crash. So we took

Dr. Towfigh (00:09:09):
Him

Dr. Cordero (00:09:09):
To the ER and we fixed him. And so that was my welcoming.

Dr. Towfigh (00:09:14):
Amazing. Trauma surgeon doing chest surgery. Heart surgery, closing up a hole in the heart.

Dr. Cordero (00:09:20):
Yep. Yeah.

Dr. Towfigh (00:09:21):
Wow. We

Dr. Cordero (00:09:22):
Got out of it good. And so it's a very wide variety of procedures that we do.

Dr. Towfigh (00:09:30):
So when you train in Central America, I assume the training is actually quite similar to the US training of residency for general surgery.

Dr. Cordero (00:09:42):
Yeah. Right now there's more differences because of robotics. We don't have robotics yet. That's something we're really pushing forward and that's my next obsession. We're all racing to get it, but pretty much the same. We have four years instead of five still. But in our intern year, we do a lot. Intern here in the US, it's pretty much a resident of first year.

Dr. Towfigh (00:10:11):
Intern

Dr. Cordero (00:10:11):
Down there pretty much is the year after you're done with med school.

Dr. Towfigh (00:10:17):
Got it.

Dr. Cordero (00:10:19):
We do a little

Dr. Towfigh (00:10:19):
Bit of

Dr. Cordero (00:10:19):
Everything.

Dr. Towfigh (00:10:21):
And most general surgeons in Costa Rica will be doing a lot of hernia surgery?

Dr. Cordero (00:10:26):
Yes. Yes.

Dr. Towfigh (00:10:27):
And the hernia surgery is mostly open or how much laparoscopic is involved?

Dr. Cordero (00:10:34):
We actually did a study that got published about it. How much, and I've gone over it. I can't tell you right now. It has been developing and it's so simple to watch history as it gets written because since we've met and we've seen the guidelines change 2018, then 2023, more and more. Private surgery pretty much is laparoscopic, minimally invasive. Rarely you would see something open. Even ETEP for ventrals.

Dr. Towfigh (00:11:09):
Very nice. Yeah. Advanced. Okay.

Dr. Cordero (00:11:12):
We did some live surgeries with IHC and it has skyrocket since then. Private surgery, which we do at Clinical Artica, it's pretty much that. Of course, complex cases, they get done open with adjunct of Botox or something else. But in the social security, I have to tell you that we are starting in different hospitals to do more and more minimally invasive. Right now we're even doing emergency cases at minimally invasive, which is something that we're pushing.

Dr. Towfigh (00:11:50):
Which is new. Yeah.

Dr. Cordero (00:11:53):
When I finished residency, there were no laparoscopic surgeries in emergency. Got

Dr. Towfigh (00:12:01):
It.

Dr. Cordero (00:12:01):
The equipment was kept. But from when I finished until I started as an attendant, we pushed every epi, every colleague to be minimally invasive. And it has been developing in the country that every resident now is prepared to do even emergency cases, even trauma cases that you can do minimally invasive. So it has been developing and it has been growing and that's where we're headed.

Dr. Towfigh (00:12:31):
So in the United States, laparoscopic hernia repairs, ventral and inguinal were starting to become a thing in the early 2000s, I would say. And then I would say the current market before robotics, before robotics still doing laparoscopic inguinal hernias was considered advanced. And a larger portion of residents would graduate not being comfortable doing a laparoscopic inguinal hernia. Many would end up doing fellowships. With robotics, that has changed. And very quickly people have learned to do robotic inguinal hernia repair, so minimally invasive inguinal hernia repair. And so overall we're doing less open surgeries and more laparoscopic or robotic inguinal surgeries and ventral surgeries. What is the status in Costa Rica?

Dr. Cordero (00:13:31):
I would tell you private would be around 50% or even more. And in social security would be around 30% maybe that we are doing minimally invasive. We only have laparoscopic and that's why we're not doing it more.Because here in the US you can approach even complex ventral hernias with robots. And as opposed as when I was here 20 years ago to now, I can see second year residents here in the US in the robot doing hernia cases like Proctor, of course. And I can't see how they fix that gap in proficiency, like surgical skin with the robots because second year residents now you see them, they're on the -

Dr. Towfigh (00:14:19):
Very skilled.

Dr. Cordero (00:14:19):
Robot and they're doing cases. As before, I even saw senior residents, they were not at that level. So I've seen how the robot here in the US fill in that gap.

Dr. Towfigh (00:14:35):
Got it.

Dr. Cordero (00:14:37):
But in Costa Rica, yeah, we are working now to train our residents. They get trained in general laparoscopic hernia. There's not like a robust course, but we're working on it. I think it's developing. So first the attendance - 

Dr. Towfigh (00:14:56):
Got it. That's very impressive. I mean, Costa Rica is not exactly the biggest country. And

Dr. Cordero (00:14:59):
It moves so fast. It's because we have a social security that encompasses over 90% of the population.

Dr. Towfigh (00:15:07):
And that's

Dr. Cordero (00:15:08):
Why everything gets done in a similar kind of way. Then we're the same people that are in public healthcare and private healthcare.

Dr. Towfigh (00:15:16):
Got it. So as a surgeon, are you mandated to work in the public system? No. Okay. So some people choose to be in the public system. Some people choose to be in the private system, and then you have people that do both.

Dr. Cordero (00:15:30):
That do both. Yeah.

Dr. Towfigh (00:15:31):
Okay. I

Dr. Cordero (00:15:31):
Would say it has been changing. Before it was over 80% that were in both. Right now, maybe around 50% are in both. People are coming out of public healthcare just because there's -

Dr. Towfigh (00:15:48):
It's exhausting.

Dr. Cordero (00:15:50):
Everywhere. There's issues with healthcare everywhere. I

Dr. Towfigh (00:15:54):
Think

Dr. Cordero (00:15:54):
It's a globe-wide crisis that we're having. And we are living in a moment where we're going to see really big changes. Here in the US, things are going to change. Things are

Dr. Towfigh (00:16:03):
Definitely

Dr. Cordero (00:16:04):
Going to change. There's a shortage of specialists everywhere in Europe, in the US, everywhere

Dr. Towfigh (00:16:10):
Else.

Dr. Cordero (00:16:11):
So we're definitely going to see changes and it's interesting.

Dr. Towfigh (00:16:15):
So as we talk, we may have patients that are in the audience that ask questions. So if you don't mind, I'm just going to ask you questions as we go that are from the audience. Do you have a sense of how much mesh is used in hernia surgery?

Dr. Cordero (00:16:32):
We push that. It's 90% unless

Dr. Towfigh (00:16:36):
You do - 90%, really? I

Dr. Cordero (00:16:37):
Would say yes. It's rare that a hernia doesn't get meshed. Only in circumstances we're not allowed. We don't have phasics in Costa Rica. We try to push that. BD got out. There's some specifics. Our laws are very strict. Okay.

Dr. Towfigh (00:16:57):
So the fancy meshes are more difficult to get, but your just traditional simple meshes are considered the go-to, or do you do a lot of tissue-based repairs?

Dr. Cordero (00:17:09):
Well, no, there's not a lot of tissue-based. Interesting. We don't have that European kind of wave. We only do so if there's an infection or you're taking off a mesh

Dr. Towfigh (00:17:19):
Or

Dr. Cordero (00:17:20):
Something that contraindicates or it's a clear contraindication to use a mesh.

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

Dr. Cordero (00:17:26):
If it's an elective surgery, you're getting mesh. So the

Dr. Towfigh (00:17:28):
Patients in the public system don't get charged extra to get mesh?

Dr. Cordero (00:17:34):
No.

Dr. Towfigh (00:17:35):
Interesting.

Dr. Cordero (00:17:36):
When I was president of the hernia in Costa Rica, we opened the market because we were supposed to use only what we had. And for example, we only had ultrapro, which is a great mesh, but it's a lightweight and you cannot -

Dr. Towfigh (00:17:49):
It's ultra lightweight. Yeah. It's not appropriate for most people.

Dr. Cordero (00:17:56):
Indicated according

Dr. Towfigh (00:17:57):
To

Dr. Cordero (00:17:58):
Guidelines. We changed that. So now we have Dextile, we have ProGrib, we have even European meshes. The only thing that we lost was BD just because they lost some permission. And it's really tricky to go through our Ministry of Health. So they're working

Dr. Towfigh (00:18:18):
On - Got it. The question is, do either of you two surgeons ever consider using glue fixation in any of your patients? Do you use glue fixation?

Dr. Cordero (00:18:28):
Of

Dr. Towfigh (00:18:28):
Course. For ventral, inguinal, what?

Dr. Cordero (00:18:30):
Inguinal. There's a lot of use. Ventral, not that much. More for inguinal. We have glue brand, which is from Italy.

Dr. Towfigh (00:18:42):
We don't have it here.

Dr. Cordero (00:18:44):
You don't have glue brand here?

Dr. Towfigh (00:18:45):
No. Well,

Dr. Cordero (00:18:47):
When we are in the European country -

Dr. Towfigh (00:18:48):
We don't have the Italian glues. We just have the - Oh, good.

Dr. Cordero (00:18:52):
I met with the engineer. It's so good. That glue is amazing.

Dr. Towfigh (00:18:58):
Is this because of Campanelli's study? I

Dr. Cordero (00:19:01):
Guess he did something with it, but Instagryl for Histagryl, we also have. And that tends to form some kind of adhesions or it dries really quick. But this glue brand, it's almost like a gel. But yeah, when you talk to the Italian engineer that development, he's the edge -

Dr. Towfigh (00:19:23):
Never heard of it actually.

(00:19:25):
I'll tell you a cute story. When I started my first job at USC, it was with Namir Katkuda, who you may recall. And he was the original investigator for the randomized prospective clinical trial of using glue fixation for laparoscopic inguinal hernia repairs. And at that time we used the Baxter fibrin glue. And I was like, "This is interesting." I was not trained to that when I was a resident at UCLA and then going to USC. It was a different way of doing things. So I started using fibringlue and it worked really well. And then he did a separate study. Sorry, he had the first pig study, and then he did a second study for pigs for ventral hernias. And the glue didn't work as well for ventral hernias. The

Dr. Cordero (00:20:15):
Ventral doesn't work as good. And

Dr. Towfigh (00:20:17):
You

Dr. Cordero (00:20:17):
Find sometimes it prevents the mesh to incorporate with the tissue, I think. If you use a lot, it's not the same. In inguinal, I don't see that problem.

Dr. Towfigh (00:20:32):
So the thought of glue as opposed to suture fixation or track fixation is that you get a wider surface area of adhesion of the mesh to the tissue. It's kind of like the progrip mesh that has the Velcro. When you'd use the Velcro, the whole surface is adhesed. Whereas if you just use flat mesh and you sew it in places, you're only quilting it in certain places where the stitching is. But with the glue, you can kind of spread it.

Dr. Cordero (00:21:07):
Yeah. But we don't use that much. And you're not supposed to use that much glue with the mesh.

Dr. Towfigh (00:21:12):
Yeah.

Dr. Cordero (00:21:13):
Same thing. It prevents the mesh to become one with the tissue and incorporate some peoples. We have used, I think, fibrin glue in some linguinals, but we don't use - What

Dr. Towfigh (00:21:27):
About for open surgery? Do you use it for open surgery? The glue?

Dr. Cordero (00:21:31):
Open surgery? No.

Dr. Towfigh (00:21:32):
No, because the Camponelli Temelli trial was using glue fixation for the onlay inguinal mesh. It really didn't catch on. No. But he said the trial was a good trial.

Dr. Cordero (00:21:46):
Yeah. But I mean, I don't see the point because that's very expensive. I mean, if you're open, you might as well just use the stitches.

Dr. Towfigh (00:21:57):
Stitches. Yeah.

Dr. Cordero (00:21:57):
They're saying that I have to tell

Dr. Towfigh (00:21:58):
You - Well, the risk was risk of tearing or trapping a nerve was theoretically reduced. Yeah.

Dr. Cordero (00:22:07):
I can see that for sure. But if you see the nerves and you identify them, you should not. A

Dr. Towfigh (00:22:12):
Lot of ifs. It's a lot of ifs. We would like everyone to do that, but as you know -

Dr. Cordero (00:22:19):
It doesn't happen. Yeah. It

Dr. Towfigh (00:22:21):
Doesn't happen.

Dr. Cordero (00:22:22):
Very interesting. In Costa Rica, we are the top three country to use ProGrip. We are one of the countries that use more ProGrip than any other country. And we love it. And I love it. When I put a ProGrip and I see the mesh there - I

Dr. Towfigh (00:22:38):
Love it too. Yeah. I go to sleep so heavy. Yeah, I agree. I agree. Because

Dr. Cordero (00:22:43):
I know the mesh is there. I know it's not super heavy. So if you have an M3 or something like that, you should use something else because it's a little lightweight. But we love ProGrip. We use it a lot.

Dr. Towfigh (00:22:57):
Here's another follow-up question to that. When using metal tack fixation to secure the mesh during laparoscopic or robotic inguinal hernia repair, or maybe even ventral hernia repair, I think inguinal, are you placing the tacks in the floor of the inguinal canal? And if so, how do you avoid grabbing any nerves when the tacks penetrate into tissues that have nerves? Which I believe you cannot see from below using the scope. Yeah. Answer that.

Dr. Cordero (00:23:31):
I have rarely used tags for inguinals. I think they're not good. They don't bring any benefit and they can bring a lot of problems and a lot of pain.

Dr. Towfigh (00:23:45):
So you use glue as your fixation?

Dr. Cordero (00:23:48):
Maybe at the beginning we use some tacs, but we don't use a lot of tacs. Maybe for eye palms, but for inguinals, it's very rare. Only if it's super big or -

Dr. Towfigh (00:24:04):
Yeah, I would agree. I think most inguinals do not need fixation. We

Dr. Cordero (00:24:08):
Don't need

Dr. Towfigh (00:24:09):
The tension. But if they're large, I think for femoral I use it because I don't want the mesh to move. The large direct or even large indirect, you can use something to hold it in place.

Dr. Cordero (00:24:23):
We can use glue or we use progrip. But if

Dr. Towfigh (00:24:27):
It's a

Dr. Cordero (00:24:27):
Very large one, then I would prefer to use either glue or a stitch.

Dr. Towfigh (00:24:33):
Yeah. So the point is true in that tack fixation, it's like a little screw and it goes into the muscle. So if you place it where there is a nerve running, obviously you can injure that nerve. Usually we know where not to put the tax so that we don't entrap a nerve. So when it is placed through muscle, we place it where there should not be a nerve. There's what's called a triangle of pain, which is where the nerves run and you don't put tax there. So I think that's the answer. But in a really thin patient and a very aggressive tacker person, I guess you could imagine injuring it, that's when judgment falls into place. Okay. You mentioned that you're the top three nation in using program mesh. How would you rank your nation in terms of hernia surgery in Central America?

Dr. Cordero (00:25:30):
I would have to be honest and say, and I think we have some colleagues that I invited. And they considered that also. They have said that to us.

Dr. Towfigh (00:25:40):
Yeah, I see some friends from. Yeah, I see some friends watching. I would

Dr. Cordero (00:25:45):
Like to hear him because -

Dr. Towfigh (00:25:47):
Raul, Jose, they're all here. Yeah.

Dr. Cordero (00:25:49):
That we have been kind of pioneers in the area, but I would like to hear what Raul has to say about that because now they have been doing amazing stuff. But I think he would agree that we were kind of the pioneers in the area. We were the first hernia society in Central America.

Dr. Towfigh (00:26:09):
Well, before Mexico?

Dr. Cordero (00:26:12):
No, after Mexico.

Dr. Towfigh (00:26:13):
After Mexico.

Dr. Cordero (00:26:15):
America still.

Dr. Towfigh (00:26:16):
Yes, yes, yes.

Dr. Cordero (00:26:17):
We were after Mexico. They're like our dad.

Dr. Towfigh (00:26:23):
I love it.

Dr. Cordero (00:26:24):
Yeah. Yeah.

Dr. Towfigh (00:26:25):
I felt that. I felt that. As part of our international hernia collaboration session in San Jose in Costa Rica, we did live surgery and the facilities were great. The facilities, the hospital was fantastic, really enjoyed.

Dr. Cordero (00:26:43):
We have joint committee approval and everything. Oh,

Dr. Towfigh (00:26:47):
Very Americanized.

Dr. Cordero (00:26:48):
Yeah. Yeah.

Dr. Towfigh (00:26:49):
Very Americanized. Do you see Americans come to Costa Rica for their operations?

Dr. Cordero (00:26:54):
Yes. We do have a lot of medical tourism.

Dr. Towfigh (00:26:57):
Yeah. I think it's a beautiful country. It's safe. It's relatively inexpensive compared to the United States economy. And you're very advanced.

Dr. Cordero (00:27:08):
And if your insurance covers it, it'd be nice to recover in a tropical nice place. So we do have a lot of medical tourism for bariatrics, dental work and some other types of surgeries. It's been years.

Dr. Towfigh (00:27:27):
Yeah. I love it. Okay. So more questions. Why is there sometimes a need for a penetrating fixation in a tap inguinal hernia? By the way, these are not doctors that are asking questions. These are very advanced questions because the audience is just so advanced. Sometimes a need for penetrating fixation in tap inguinal hernia repairs if the intraabdominal pressure is pushing against the mesh, supporting it, staying in the desired position behind the ingual floor, even in an M3. So M3 is a very large direct hernia. I don't even like doing those lap. I like doing those open because you can safely close that defect.

Dr. Cordero (00:28:10):
Or do a tap, but I mean, I'm telling you what I saw here in the US. You do tap for really smaller inguinals.

Dr. Towfigh (00:28:21):
Tap

Dr. Cordero (00:28:23):
Or E-tap,

Dr. Towfigh (00:28:24):
Right? Yeah.

Dr. Cordero (00:28:25):
If you have an M3 or L3 or some complication, you would do a tap, either robotic or laparoscopic or you do. And if you do fixation, then you would use stitches.

Dr. Towfigh (00:28:42):
Yeah. But I think the idea that your abdominal pressure will hold the mesh against a large defect is not correct because it will actually push the mesh into the large defect if you don't fixate it or if you don't close the defect to allow for a larger proportion of the mesh in contact with normal tissue.

Dr. Cordero (00:29:03):
I think that idea would work for smaller hernias, but defects, like we are talking about M3s or L3s, which is bigger than two centimeters, that is not true because the mesh gets pulled into the defect. So it needs to be fixed.

Dr. Towfigh (00:29:22):
Okay. I have a patient who I know lives in Mexico part-time and is a very smart man. He follows me and I love him so much. So his question is, because Costa Rica habits one of the blue zones, i.e. The Choroteca in Guanacaste, are recovery rates accelerated compared to other countries since Costa Ricans Ticos are renowned for longevity and health. Can you explain what I just read?

Dr. Cordero (00:29:57):
Where's that question?

Dr. Towfigh (00:29:59):
Oh, it's in the Facebook. The live section.

Dr. Cordero (00:30:01):
Oh, okay. I was trying to see it, but we do have a blue zone, but what is he asking if we have

Dr. Towfigh (00:30:06):
One? Are recovery rates accelerated compared to other countries? Since the Ticos are renowned for longevity and health. I mean, you've been in New York for two years. Have you noticed a difference?

Dr. Cordero (00:30:22):
There's a difference just like when you compare Americans to Europeans. The IMC is different. The diet is different. Of course, if you are a morbidly obese patient that has many comorbidities, your follow-up and the recovery would be very different. But I would not say because of the area. We have very unhealthy people as well. Things are eating habits have changed. So I wish we could be in the blue zone. The blue zone is in the North Pacific, which is. And actually Dr. David Chen came with me to have live surgeries there one point before the IHC. They were on vacation and I took him to do some live surgeries there.

Dr. Towfigh (00:31:28):
So what was the blue zone?

Dr. Cordero (00:31:30):
That blue zone, if you look, there's a documentary on Netflix. There's some places here on earth. In Japan, there's other in the Mediterranean and there's one in Costa Rica in the North Pacific, which is Nicolea, La Panisa, that region he's talking about. It's places where people live longer, healthier. And

Dr. Towfigh (00:31:52):
It has to

Dr. Cordero (00:31:53):
Do with the diet. And it has to do also with their daily living. They're very active people. So you

Dr. Towfigh (00:32:01):
See

Dr. Cordero (00:32:01):
90 year old people doing chores like they're 50. So they live longer. I think what it proves is that if you eat healthy and you stay active, it's better for you. But yeah, there's a documentary on Netflix about it.

Dr. Towfigh (00:32:19):
Do they get hernias? They probably get hernias.

Dr. Cordero (00:32:21):
They do. I mean, I have a really good resident of mine who's now the boss there. They do get hernias. They do get cancer. Lately, they have been getting more gastric cancer and the rest of the world. And it's because they have open fast food restaurants in the area as well.

Dr. Towfigh (00:32:39):
No. There's McDonald's in the blue zone? Karamba.

Dr. Cordero (00:32:47):
Yep. So as we evolve, it's the same with diverticulitis. When you're eating habits and your habits change, this Western society kind of. You remember Asian people were not used to get diverticulitis or problems like that. But as the diet changed and

Dr. Towfigh (00:33:07):
It's mobile

Dr. Cordero (00:33:07):
Everywhere, pretty much are getting the same sickness.

Dr. Towfigh (00:33:13):
Okay. Another question. It's about treatment of chronic pain. Can high resolution ultrasound above 15 to 30 megahertz be useful to find small hernias or diagnose nerve irritation or entrapment or chronic pain? Do you guys use much ultrasound or is it like you ask where they just go straight to CT or MRI?

Dr. Cordero (00:33:36):
No, we do use a lot of

Dr. Towfigh (00:33:38):
Ultrasound A lot of ultrasound. More and

Dr. Cordero (00:33:39):
More we're using CT or even MRI, but we have ultrasounds even in our consultory.

Dr. Towfigh (00:33:48):
In your office?

Dr. Cordero (00:33:49):
Yeah, in our office. Even the butterfly that you can plug to your phone and do the tap yourself.

Dr. Towfigh (00:33:58):
Fantastic. That's amazing.

Dr. Cordero (00:34:00):
But sometimes, because this is a topic that we're going to touch in the upcoming American Hernia Society. There's going to be a debate about that, ultrasound, because it's different when radiologists, what they tell us and then what we find.

Dr. Towfigh (00:34:17):
Yes, very true. That's a big peeve of mine. So in the United States, ultrasounds are typically not as well done and not as frequently done for hernias and identifying nerves and nerve entrapment, neuromas, et cetera. I mean, it can be done. There are certain specialized centers, like I believe Cleveland Clinic has a good one where they have a really talented ultrasound doctor, not just a tech that does it. I have one doctor that can do it, but I really can't rely on anyone else doing ultrasounds well like that in the US.

Dr. Cordero (00:34:57):
We don't have technicians doing ultrasounds. I almost had a heart attack when technicians do things here.

Dr. Towfigh (00:35:03):
That's a problem for us.

Dr. Cordero (00:35:05):
And that's a shortage. And then you have technicians, PAs, NPs, and you keep developing.

Dr. Towfigh (00:35:15):
The problem with the US is you order ultrasound. First of all, you have to order it correctly. It has to be a dynamic hernia ultrasound. You can't just say hernia ultrasound or groin ultrasound or anything like that, or abdominal ultrasound. They'll never look for a hernia. And then a tech does it, and then the images are sent to the doctor. And often those two people don't talk to each other. At the most, maybe the tech will write a little note like, "The patient was painful when I touched this area." And then you lose all that information. Whereas the one doctor that I'm talking about that's local to me, he is the radiologist that does the ultrasound himself. So he's like a doctor. He talks to the patient, examines the patient, determines the right imaging, and then there's an interaction. That will increase the rate of you finding something abnormal.

(00:36:10):
But still, I think finding a tiny hernia or looking at nerves, it's very specific. And most radiologists are not trained to look for that. If they have a working relationship with a hernia surgeon, let's say, where we can talk with them and say, "This is what I'm looking for," they may look for it. Otherwise, they may not consider what we are looking for to be clinically relevant.

Dr. Cordero (00:36:34):
You need to have a relationship. First of all, the most important thing is that training. They need deep

Dr. Towfigh (00:36:39):
Training

Dr. Cordero (00:36:40):
Because it's not the same as anything else. And we might think it's not something that it's a big deal, but it is. I mean, you need training and it's different. And then it's operator sensitive

Dr. Towfigh (00:36:54):
Ultrasound.

Dr. Cordero (00:36:55):
So like you say, if they don't even talk, they don't know what they're looking for. It's not the same. We do have reliable radiologists that work in our hernia clinics. They are

Dr. Towfigh (00:37:08):
As

Dr. Cordero (00:37:09):
As a CAT scan, but they are working with our hernia clinics. And like I said, many of us in the area, like Dr. Rodriguez in El Salvador, who is developing a really strong ultrasound program, we have ultrasounds in our office.

Dr. Towfigh (00:37:28):
Fantastic. Yeah, that's really great. I have one in my office, but it's not common in the United States, unfortunately. Okay. Next question. You use Program a lot. Can Program provide some support in an M3? So very large direct inguinal hernia in an individual who is elderly and does not do much heavy exertion?

Dr. Cordero (00:37:51):
Could. It could, but it's not the optimum.

Dr. Towfigh (00:37:57):
It's not

Dr. Cordero (00:37:57):
The best in the guidelines.

Dr. Towfigh (00:37:58):
Because you're bridging. We don't like bridging, especially the larger the hernia.

Dr. Cordero (00:38:03):
And nowadays we're closing, right?

Dr. Towfigh (00:38:06):
Yes.

Dr. Cordero (00:38:06):
And some people are even closing in directs, which is not a message that I can give to everybody responsibly

Dr. Towfigh (00:38:12):
Because

Dr. Cordero (00:38:13):
It can create a lot of problems.

Dr. Towfigh (00:38:15):
Yes.

Dr. Cordero (00:38:15):
But at least direct, we do intricate so the mesh has a better place to lay on and don't get sucked into the defect with

Dr. Towfigh (00:38:28):
Direct.

Dr. Cordero (00:38:29):
But interacts, that's still controversial.

Dr. Towfigh (00:38:32):
Next question.

Dr. Cordero (00:38:33):
Would be

Dr. Towfigh (00:38:33):
A

Dr. Cordero (00:38:34):
Little light for that.

Dr. Towfigh (00:38:36):
Okay. That basically is tacking to what you're saying. Can a laparoscopic mesh repair without closing the inguinal floor provide some support in the enlarged direct hernia even if it is an imperfect repair in someone who does not do heavy exertion?

Dr. Cordero (00:38:53):
Like I said, that's why we are moving to closing those defects.

Dr. Towfigh (00:39:02):
Yeah. Yeah. It's best if it's closed or imbricated or some type of tissue is there instead of just the whole. Okay. What are some special meals and foods unique to Costa Rica? I have

Dr. Cordero (00:39:14):
To ask Shirin, what was your favorite meal you had when you were down there?

Dr. Towfigh (00:39:18):
Okay. I will tell you. I'm forgetting the names because the foods were so good. But first of all, the fruits were amazing. I had a trip. So for those of you, just to catch up, when I went to Costa Rica, I decided I should take some time off for my own wellness too. So after the meeting, I think I took two days in addition to just chill. And I went in the center with the. I didn't go by the beach. I went in the center with the volcanoes.

Dr. Cordero (00:39:58):
That's San Carlos. That's in the northern area.

Dr. Towfigh (00:40:00):
Yes. Starts with an M.

Dr. Cordero (00:40:04):
La Fortuna.

Dr. Towfigh (00:40:06):
La Fortuna. Yes. La Fortuna.

Dr. Cordero (00:40:08):
There's a volcano there. There's a lagoon.

Dr. Towfigh (00:40:12):
There's a river and they said we can do river rafting. I was like, "Okay, I've never done river rafting. I'd love to do it." Well, they forgot about me. And the hotel was so nice, they arranged for me to have my own private river rafting. So it was me and these three guys. And they stopped in the middle of the river somewhere and they opened up something and there was fresh fruit and just took a knife out of their pocket and just right on the river of the raft, they just started cutting up pieces and handing it to me. So damn delicious, just regular fruit. But yeah, all the food was just delicious.

Dr. Cordero (00:40:54):
Even abroad, every time I go home now, it's been a year since I've been going back and forth. But one of the main difference, yeah the fruits, how fresh and delicious savory they are. Then we have rice with beans, which is called.

Dr. Towfigh (00:41:15):
Yes.

Dr. Cordero (00:41:16):
Breakfast, you can have that for lunch. So it's a lot of fiber, carbs, protein. And then also we have a lot of corn made stuff, tortillas or just from corn, different types of corn made, which is really good. But there's a little bit for everybody. And up until this day, I still discover new fruits.

Dr. Towfigh (00:41:40):
Really? My

Dr. Cordero (00:41:41):
Husband's like, "I've never tried that." There's so many weird, strange and delicious fruits, like all colors for shapes and sizes.

Dr. Towfigh (00:41:52):
I mean, we went to some really beautiful places. You may recall when we went to that, that was not a zoo, but like a -

Dr. Cordero (00:42:05):
Waterfall?

Dr. Towfigh (00:42:07):
Yes. Well, they gave us that tea. It's basically sugar tea.

Dr. Cordero (00:42:11):
Yeah. Oh my

Dr. Towfigh (00:42:12):
God. I don't think it's tea. I think it's just sugar.

Dr. Cordero (00:42:15):
It is sugar. It is. We call it aguadulce, which is like sweet water.

Dr. Towfigh (00:42:22):
So delicious. So delicious. I still have a whole packet I bought so much. It is

Dr. Cordero (00:42:29):
So good.

Dr. Towfigh (00:42:30):
Okay.

Dr. Cordero (00:42:31):
The milk is delicious.

Dr. Towfigh (00:42:33):
Okay. Dr. Raul Rodriguez is online. He says, "Thank you very much for such an interesting conversation with one of Central America's most dedicated abdominal wall surgeons." That's you, Kathy. Thank you. I would like to congratulate Dr. Cordero for being such an inspiration to all countries in our region and for supporting the advancement of abdominal wall surgery throughout Central America. This is very nice. Do you have certain countries that you'd like to kind of help out and help spread the love to?

Dr. Cordero (00:43:06):
I mean, and Salvador has been like our brother in this past. And I think -

Dr. Towfigh (00:43:12):
So Mexico's the father.

Dr. Cordero (00:43:14):
Yes.

Dr. Towfigh (00:43:14):
And then you are the sibling.

Dr. Cordero (00:43:16):
Brother for us.

Dr. Towfigh (00:43:18):
Okay.

Dr. Cordero (00:43:19):
Rodriguez has been the person in charge of bringing knowledge. But they have grown so much. It's amazing.

Dr. Towfigh (00:43:29):
I love

Dr. Cordero (00:43:30):
It. Well, they just had jury for a curse. They're doing amazing things with simulation models, ultrasound, really complex cases. And if my memory, I mean, Dr. Rodriguez is the one who really was a pioneer in this with his group.

Dr. Towfigh (00:43:49):
I love

Dr. Cordero (00:43:50):
It. I can tell you Honduras, it is developing and joining. Actually, Dr. Chen, Dr. Novitsky just had one of these hernia projects

Dr. Towfigh (00:44:04):
In the

Dr. Cordero (00:44:05):
Community. They do this social work and they went to Honduras and now they are being real, really strong developing.

Dr. Towfigh (00:44:15):
They go to Guatemala regularly.

Dr. Cordero (00:44:17):
Guatemala is there. And Panama is organizing. So it's been really, really rewarding to see how everybody is coming together. Nicaragua, it's a little different, but that's because of the political issues, which was a shame, but they were right there. And I just love how things have been developing in the area.

Dr. Towfigh (00:44:43):
Yeah. I love it. Those are all such great. It's so fascinating to me that Nicaragua and Costa Rica share such a wide border and yet they couldn't be more different. Yeah. Yeah. Okay. More questions. When performing a tap versus a tap inguinal hernia repair, can you dissect as extensively below? Yeah. I mean, you can dissect as extensively. Do you have any preference yourself? Tap versus tap?

Dr. Cordero (00:45:08):
More of a preference. I abide to the guidelines. If there's some issue with complication or there's bilateral, depending on the size, what tap gives you is the opportunity to check the abdominal cavity. If

Dr. Towfigh (00:45:25):
There's an

Dr. Cordero (00:45:26):
Incarceration or some kind of suffering to the bowel. So I would prefer a tap. And you do lower two centimeters as the guideline says from the Cooper to have a pulpit space to put your mesh, which you can also do in TAP. But like I said, TAP is for smaller defects, I feel.

Dr. Towfigh (00:45:48):
Yeah, definitely the large ones you cannot do TAP. Even ETAP, you might as well just do TAP.

Dr. Cordero (00:45:55):
I've

Dr. Towfigh (00:45:55):
Helped

Dr. Cordero (00:45:56):
Dr. Dyes do very complex ETAP procedures, but that's Dr. Dyes. And that's significant father of the technique surgeon. And I'm like, Dr. Dys, that's you. I mean, we cannot all do this.

Dr. Towfigh (00:46:12):
Yes. That's Dr. Jorge Dice of Columbia. He's very talented.

Dr. Cordero (00:46:17):
President of the American Hernia Society, which is wonderful.

Dr. Towfigh (00:46:21):
Yes, he is. So you brought up the American Hernia Society meeting a couple times now. April 27th, I think.

Dr. Cordero (00:46:29):
August 27th.

Dr. Towfigh (00:46:30):
Sorry, August 27th. We'll all be together in Denver. What are you doing at the meeting?

Dr. Cordero (00:46:39):
I'm moderating and I'm about advances in the area of Latin American Hernia. And I'm presenting talking about prehabilitation for the frailty patient.

Dr. Towfigh (00:46:50):
That's really lovely. I think there's so much being done in Latin America in hernias. My very first meeting outside of the US, but in Northern America was Mexico. And I was like, "Oh my God, they're so good." And then we had Costa Rica and we did Brazil after that. I mean, it's really amazing. People can tend to be so egocentric in the United States and they think no one else does better. But I must say, having worked with a lot of international surgeons, I would say, correct me if I'm wrong, from a technique standpoint, I think non-US surgeons are very talented. Technically. From an experience standpoint. Huh?

Dr. Cordero (00:47:44):
We have to cope with less technology.

Dr. Towfigh (00:47:49):
That's very true. Now, from an experience and an outcome standpoint, I feel we're more advanced. I see mistakes being done that we learned about 20 years ago that are just now being encountered in other countries that we've already gone beyond our learning curve on that. But from purely a technique standpoint, like WAD in Russia where he's doing laparoscopic TARs, the stuff some of these surgeons are doing with a limited amount of technology available to them is beyond. And yet American surgeons, if they don't have their robot, it's like they can't operate anymore. It's ridiculous sometimes.

Dr. Cordero (00:48:35):
That's what I said about my experience from 20 years ago, but definitely the robot has been filling in a gap here in the US. It's because of how the system works also. It's a private system with a lot of liability, legal issues. So I can definitely understand being in practice here. But yeah, I'm impressed of what they're doing in Armenia, in Russia, Europe. There's so many talented surgeons. If you go to Argentina or Brazil, people are amazingly skilled. Colombia, even in Central America. I think the lack of technology makes people creative and develop proficiency. But definitely the US with technology. I mean, you guys have, you're the king of secure procedures. So I think if we combine both, it'll be the best of both worlds, to be honest.

Dr. Towfigh (00:49:48):
I agree. I agree. And I feel like we really should do more of these collaborative things. It's really great that there's a Latin America session each year at the American Hernia Society. And

Dr. Cordero (00:50:00):
Like you said, I've been around in bariatrics, colorectal trauma. And I've never experienced such an environment like the American Hernia Society of teaching, brotherhood. And it shows worldwide all the projects has been done. The guidelines that have been developed between the European, the American, that's how we should do things. We should all agree and

Dr. Towfigh (00:50:32):
Look at

Dr. Cordero (00:50:33):
What's best for the patients.

Dr. Towfigh (00:50:35):
Yeah, totally agree.

Dr. Cordero (00:50:36):
How to follow the same guidelines. So I just really believe, I've never encountered such a wonderful, warm environment with surgeons as in the American Hernia Society. So I think you guys have a lot to do with how we have been developing in the area. Mexico, we have amazing people.

Dr. Towfigh (00:50:56):
Yeah. Do you treat a lot of chronic pain patients? Actually, what is the status of that? I feel like we have a lot in the United States, but it's not as much of a problem outside the United States.

Dr. Cordero (00:51:09):
My hospital is one of the main hospitals that has a hernia department.

Dr. Towfigh (00:51:16):
Yes.

Dr. Cordero (00:51:17):
I'm going to say it's one of the first ones.

Dr. Towfigh (00:51:19):
Yes.

Dr. Cordero (00:51:19):
And I remember when it was developing, they were doing only anterior component separations. I

Dr. Towfigh (00:51:29):
Was

Dr. Cordero (00:51:29):
Pushing for posterior. Then it has been evolving and it's been interesting. But luckily I've heard of only two difficult cases of pain and we operate thousands, thousands of hernias.

Dr. Towfigh (00:51:45):
Yeah.

Dr. Cordero (00:51:46):
But it's not such a common thing. I don't know. I cannot tell you why. We do infiltrate the patients post-op.

Dr. Towfigh (00:51:54):
That's how

Dr. Cordero (00:51:55):
Our teachers taught us. We do infiltrate locally and then -

Dr. Towfigh (00:52:02):
Local anesthetic and all that. How many surgeons are dedicated to hernia surgery in your clinic?

Dr. Cordero (00:52:11):
There's only two in my hospital because like I said, there was a shortage, but we all do things. But everybody does hernias. But the complex ones, it's only that department, which is now two people. For a while, it was only one person.

Dr. Towfigh (00:52:31):
Yeah. Do you do should ice and other tissue-based inguinal hernia repairs?

Dr. Cordero (00:52:37):
I mean, if you have to, that means if -

Dr. Towfigh (00:52:41):
Your residents get taught on it?

Dr. Cordero (00:52:44):
More so bassini than shouldice. I don't think. You remember when we did with Andreas? I think it takes some training. Yeah. It's not that easy as people think, even. So I think what they. And we used to be thought so much of this beautiful anatomy and procedures. And nowadays I can tell you, if I ask my residents, there's not that many uncomplicated hernias. The volume of work we do, they're all either complicated or they are complex. I don't know where the easy ones are going. I would say to the private because of the wait list.

Dr. Towfigh (00:53:29):
Yeah, yeah. Yeah. Tell me, if a patient comes to you with. One of the questions on Facebook Live is a patient with an open tissue-based, so shouldice, inguinal hernia, and now they have chronic pain. What's your algorithm for treating that?

Dr. Cordero (00:53:46):
Well, we follow pretty much the algorithm that Dr. Chen and you guys taught us. Before three months, you cannot talk about chronic pain. And you can try to do some infiltrations first with long deposit steroids, and then you can do some alcohol blockage. And then if in six months with pain modulators such as Lyrica or Gabapentin, stuff like that, things don't get better. Then you would do the neurectomy. Sometimes you would do a local one if it's entrapped within the mesh. That's with the Rigo protocol that we have.

Dr. Towfigh (00:54:30):
We

Dr. Cordero (00:54:31):
Can locate exactly. Rigo Alvarez is a surgeon from Mexico, and he developed this procedure where you can tell exactly which nerve is suffering. And if it's something local, then you fix it anteriorly and you do the neurectomy. Or if not, you do a posterior neurectomy with.

Dr. Towfigh (00:54:51):
So the issue with. I would say people in the United States for sure, many of them choose a non-mesh repair because they think there'll be no chronic pain and they don't want chronic pain. So they're like, "I don't want mesh." When you ask the patient, why not? They say, "Because I don't want chronic pain." But the studies have all shown there's an equal amount of chronic pain with a tissue repair. So what people don't appreciate necessarily is that a tissue-based repair doesn't give you chronic pain from the mesh because there's no mesh. And there's always risk of nerve injury with either of those operations. So that's what you kind of pointed to. But there's another thing about tissue repair, which is this idea that because we're completely relying on your tissue, there's a risk of it tearing. We know the risk of recurrence is higher with a tissue repair than a mesh repair.

(00:55:50):
And how you tear is that you're constantly pulling on those stitches and you're tearing. That's where a lot of the chronic pain is. It's that impending tear or that constant status of tearing. And people are always looking for a nerve that's being injured, but it's not a nerve. It's either a recurrence or it's an impending recurrence where you're tearing. And that act of tearing the muscle can be quite painful. And often you need a mesh repair to take the tension off of the tearing or tight should ice repair. I don't know what your experience

Dr. Cordero (00:56:27):
Has been. We don't have bico meshes. We don't have basics. We don't do a lot of tissue repairs unless it's a catastrophe and you cannot use a mesh.

Dr. Towfigh (00:56:37):
Yeah.

Dr. Cordero (00:56:38):
We don't have chronic pain. It's less than 10, 15%. I don't know if it's because people don't complain about it or -

Dr. Towfigh (00:56:50):
That was my question. I mean, is it the patient? Are they just more accepting of a complication or pain or more tolerant of pain? Or are they healthier? I don't know. I don't know why. Most of the chronic pain is in the US.

Dr. Cordero (00:57:17):
Study perspective, multi-institutional study. Because seriously, we have very little chronic pain.

Dr. Towfigh (00:57:29):
Very,

Dr. Cordero (00:57:30):
Very, very little.

Dr. Towfigh (00:57:31):
And

Dr. Cordero (00:57:32):
You know there's some specific type of patients that are more prone to pain. If you have a pain that has a smaller hernia with a lot of pain, that's not a good sign. There's something

Dr. Towfigh (00:57:42):
Else going

Dr. Cordero (00:57:43):
On. Find that before you operate on them. I don't know if it's because they either wait longer. I don't know. I don't know what to tell you.

Dr. Towfigh (00:57:53):
Even

Dr. Cordero (00:57:53):
In private surgery, that should be a very interesting study, but it's not a big problem for us.

Dr. Towfigh (00:58:00):
I know. And I've seen that. Even in China, India, where they're doing millions probably, they have patients with chronic pain and I see them, but it's not like what we see in the United States.

Dr. Cordero (00:58:11):
That's bad. Even in Europe, I don't know. This movement started in Europe. And I mean, we don't have the perfect mesh yet, but we have really good mesh.

Dr. Towfigh (00:58:23):
Yeah. Yeah. Yeah. I'm very impressed with the opportunities in Costa Rica. So you're currently in New York. Are you practicing in Costa Rica?

Dr. Cordero (00:58:33):
Yeah. I still don't want to practice here just for family reasons. I have my tenure back home. I still haven't decided. There's been changes in the American healthcare system and I've been offered and sometimes pushed, but I'm still reluctant to do the jump. But I have my issues, but I don't know, maybe if I find the right place, but it hasn't been there yet. I don't know. The system is different. I'm used to something else.

Dr. Towfigh (00:59:17):
Okay. We're going to have to talk when we see each other in Denver in two weeks.

Dr. Cordero (00:59:25):
I was taught and I was raised in a public healthcare system and a public institution. So for me, that side of medicine is very important.

Dr. Towfigh (00:59:36):
Yes. And if someone wants to come and see you in Costa Rica, how can they reach you?

Dr. Cordero (00:59:41):
Oh, just ClinicalBiotic. I mean, it's really hard to find me, but patients do find me. Even if I'm here, I still manage cases with my colleagues and associates. If they wait for me, so when I go, I schedule them, have happy patients. But I do have my associates there also to take care of people. So in they can just -

Dr. Towfigh (01:00:06):
Clinica Bimlica and Clinica HRN?

Dr. Cordero (01:00:09):
Yeah. I'm pretty much around everywhere, but yeah.

Dr. Towfigh (01:00:13):
Okay. All right. Well, that brings us to the end of our lovely hour with you.

Dr. Cordero (01:00:22):
Imagine. We have so many questions. Look at

Dr. Towfigh (01:00:24):
That. I know we have more that we didn't get to, but that's just the reality of life. Dr. Cordera, I'm so happy to have you. Thank you for giving me your time. You're on East Coast time, so I appreciate you're away from family to be with me and to entertain the questions that I've asked. And thank you for doing such an amazing job in promoting high level hernia surgery in Central America, especially in Costa Rica, and neighboring friends. And we all love you and thank you for being our guest.

Dr. Cordero (01:00:59):
Thank you so much. Thank you for the opportunity. I love you guys back. You have been an inspiration personally and for a lot of us. And really it has been you guys giving us the opportunity to shine and show what to do and the rest of the Central America area. There's amazing people doing amazing things. I'm glad we are given the chance to perform that and showcase that. So thank you for the opportunity.

Dr. Towfigh (01:01:32):
Thank you. And that's the end of it for us. Please subscribe to my YouTube channel at HerniaDoc. We have over 200 episodes with amazing guests, just like Dr. Cordera, and really great questions being answered by you all. Thank you for those of you who follow me on Facebook at Dr. Tophi and at Beverly Hills Hernia Center. Same on Instagram and Twitter. And with that, I will see you next time. Thanks everyone. Bye-bye. Bye-bye. Thank you, Kathy.

Dr. Cordero (01:02:04):
Oh, it was so lovely. It

Dr. Towfigh (01:02:06):
Was wonderful.

Dr. Cordero (01:02:06):
This guy from Honduras disconnected. He's adorable. I'll talk

Dr. Towfigh (01:02:11):
To him. Oh, okay. I'll see you in Denver.

Dr. Cordero (01:02:13):
Yes. We have to talk.

Dr. Towfigh (01:02:15):
We will. Take care. Bye-bye. Bye.