Medical Insider Blog

Minimally Invasive Hernia Repair

  • Posted Apr 25, 2016
  • Michael Perez, MD

One of the most common reasons individuals seek surgical medical attention is for hernia repair. Over 600,000 hernias are repaired annually in the United States alone, the majority on an outpatient basis. 

Hernias commonly occur at natural openings in the body such as the umbilicus, inguinal canal or esophageal hiatus. They can also occur at sites of previous surgical incisions. When a loop of intestine or abdominal tissue pushes into the hernia sac, severe pain and other potentially serious complications can result.

There is no adequate nonsurgical medical treatment for a hernia. Under certain circumstances the hernia may be watched and followed closely by a physician. These situations are unique to those individuals who are at high risk for operation. Minimally invasive hernia surgery has been perfected in the past 2 decades. The goals are: to reduce pain, improve outcomes and reduce the time of recovery. In laparoscopic minimally invasive hernia surgery, a telescope attached to a camera is inserted through a small incision. This technique is the same whether or not robotic assistance is employed. Other small incisions are made in the abdomen.

The hernia defect is reinforced with a mesh and secured in position with stitches or staples, depending on the preference of the surgeon. The principles of surgical repair involve the use of prosthetic mesh to repair defects in order to minimize tension on the repair. A tension free repair has a lesser chance of hernia recurrence. In addition the risk of infection is markedly decreased compared to traditional open hernia repair. In fact, for inguinal hernia repairs, we can even perform the dissection in the extraperitoneal space, avoiding any intra-abdominal adhesions.

For all types of minimally invasive hernia repairs, patients are able to return to normal activity much faster. My experience with minimally invasive inguinal hernia repairs has shown that patient can even return to full athletic activity within 1-2 wks. A patient is a candidate for laparoscopic hernia repair if they are medically able to undergo the appropriate anesthesia. Also, the defect must be in an area that allows the surgeon to place the laparoscopic or robotic trocars in positions where repair is possible. In some very large hernias, the abdominal wall is distorted to such a degree that it is impossible to safely place laparoscopic instruments. Even in these cases the techniques learned with minimally invasive surgery can be applied to decrease the trauma of open repairs.

Patients with hernias should be referred to appropriately trained surgeons to assess the feasibility of minimally invasive hernia repair. Minimally invasive surgery involves laparoscopic techniques and robotic assistance may be appropriate as well.

Click here to learn more about Dr. Michael Perez.

Stretching: The Truth

  • Posted Nov 04, 2015
  • M. Alicia Edwards, MS, ATC

Stretching has been greatly studied in the past 15 years, and the results are in: static stretching is no longer a prerequisite to exercise and sport. Dynamic stretching has taken its place when preparing muscles and joints for physical activity. There are many questions that arise when it comes to exercise prep and optimizing performance:

               Are you still an avid pre-exercise static stretcher?         
         What is dynamic stretching? 
   Do you warm up?     Should you cool down?

Let's discuss each of these further.

Low Load Long Duration (Static) Stretching

Static stretching is defined as "to stretch muscles at rest." This seems counterproductive when we think about the times this type of stretching is most often performed – before exercise or sport. According to research, this type of stretching has been shown to actually decrease athletic performance. This fact is well known around the strength training community, and studies have only recently been testing the effect of this type of stretching with endurance athletes. Prolonged static stretching of a muscle and tendon decreases its 'stretch response,' which is a response where the muscle and tendon stores energy when it is stretched quickly.   When this reflex decreases, the muscles are weaker, subsequently decreasing performance.  So, you may be wondering, "Is static stretching even necessary?" The answer is YES, as long as it is done at the end of the exercise. Lengthening muscles and tendons is an important part of every physical activity routine and is appropriate for all ages.

Dynamic (Functional) Stretching

Dynamic and functional stretching help lubricate the joints and prepare the body for the bulk of the activity or workout. This is done by stimulating the same 'stretch response' we previously discussed. This type of stretching stores energy within the muscles and tendons and will translate to increased reflex response and athletic performance. For lower body, athletes' functional movements may include things like bodyweight squats, high knees, jumping jacks and lunges. For upper body athletes like overhead throwers or swimmers, these moments may include arm swings, arm circles and push-ups. 


For most people who currently participate in an active lifestyle or play a competitive sport, the concept of completing a warm-up prior to activity is a no-brainer. A proper warm-up is a proven way to help decrease the risk of injury, as well as increase athletic and physical activity function.  A warm-up is a mild to moderate physical activity that increases blood flow to the upper body and lower body musculature. It literally 'warms up' the muscles and joints, prepares the cardiovascular system for increased work and increases the body temperature. Hemoglobin in the blood releases oxygen easier at a higher temperature. Translation: more oxygen and blood to the muscles equals better performance. 

Cool Down

Cooling down after strenuous activity allows the body to gradually return to homeostasis. Homeostasis is 'your body's happy place.' It is when your body's internal functions are regulated at a normal, comfortable state. Letting the body cool down can be a safer way to complete exercise. How many people (including yourself) have you known to become faint or dizzy following exercise? Part of the reason this happens is because exercise is ended abruptly. This allows blood to pool in the large muscles groups of the legs. Slowly decreasing activity will let the body slowly readjust and redistribute the blood, decreasing the risk of becoming faint or lightheaded.

What does all this mean?

So, the take away is this: no matter what activity you are performing, a proper warm-up is always the first step, followed by dynamic stretching, cool down, and finally, static stretching.  The simple rearrangement of these components may very well be the key to better performance!

Stay tuned for next month's topic:  "Adhesions are the Reasons?" We'll discuss chronic tightness from myofascial restrictions and adhesions, how to find out if you have an adhesion and what you can do about it.

M. Alicia Edwards, MS, ATC, is a certified athletic trainer who practices with Holy Cross Orthopedic Institute Fort Lauderdale's Sports Medicine Program. For a sports medicine physician referral, call 954-900-6653.

Understanding Urinary Incontinence

  • Posted Oct 19, 2015
  • Anele R. Manfredini, MD

Urinary Incontinence (UI) is a condition involving an involuntary loss of urine that affects millions of women. The risk of public embarrassment may keep patients from enjoying many activities. When urine loss occurs during sexual activity, it can cause tremendous emotional distress.

Women experience UI twice as often as men. Pregnancy, childbirth, menopause and the structure of the female urinary tract account for this difference. However, both women and men can become incontinent from neurologic injury, birth defects, stroke, multiple sclerosis and physical problems associated with aging. Most cases of UI affect older women, but it can be seen at all ages.

Reversible Causes of Urinary Incontinence

There are reversible causes of UI that should be excluded before extensive work-up:
D - Delirium
I - Infection
A - Atrophic vaginitis or urethritis
P - Pharmaceuticals
P - Psychological disorders
E - Endocrine disorders
R - Restricted mobility
S - Stool impaction

Types of Urinary Incontinence

Stress Incontinence: involuntary loss of urine during an increase of intra-abdominal pressure produced from activities such as coughing, laughing or exercising.

Overactive Bladder / Urge Incontinence: the involuntary loss of urine preceded by a strong urge to void, whether or not the bladder is full.

Overflow Incontinence: urine loss associated with overdistension of the bladder, typically caused by an underactive bladder (detrusor) muscle and/or outlet obstruction.

A diagnosis of UI can be made on the basis of a history, a good physical examination and laboratory tests.

Treatment Options for Urinary Incontinence

Stresss Incontinence: Treatment includes the rehabilitation of pelvic floor muscles through the use of pelvic muscle exercises (Kegel exercises), weighted vaginal cones and pelvic floor electrical stimulation. Other options include occlusive devices such as pessaries, alpha-adrenergic drugs and local estrogen replacement therapy (ERT).

Overactive Bladder: Treatments include behavioral therapy, pharmacologic agents, pelvic floor electrical stimulation, extracorporeal magnetic innervation, local ERT and neuromodulation.

Mixed: Treatment is based on the predominant symptom.

Overflow Incontinence: Treatments include medications, catheters to empty the bladder if necessary; and if no improvement, then surgery.

Physical Therapy / Rehabilitation

Physical therapists evaluate and treat joint dysfunction, muscle tightness, and weakness or imbalance in muscle groups. Women's health physical therapists, trained in the area of pelvic health, can identify possible reasons for pelvic floor dysfunction and develop a treatment plan, with your physician, specific to you. They may use hands-on techniques to address muscle tightness, or give you targeted exercises to improve muslce strength and correct problems. Other treatment strategies include biofeedback, postural training and strengthening of the core muscles.

Benefits of Physical Therapy

• Gives you control over your life and your bladder
•  Saves money and embarrassment by allowing less use of pads and undergarments
• Reduces use of medications for incontinence
•  Possibly prevents the need for surgery

Reference: Am Fam Physician. 2000 Dec 1;62(11):2433-2444

Dr. Anele Manfredini is a family medicine physician who specializes in women's health and practices at our Holy Cross Dorothy Mangurian Comprehensive Women's Center in Fort Lauderdale, FL. Our Women's Center also offers Women's Health Rehabilitation Services that offer treatments for pelvic floor dysfunctions and women's health issues. For referral information for Dr. Manfredini and/or Women's Health Rehabilitation Services, call 954-900-6653.

Abnormal Uterine Bleeding: Advances in Treatment

  • Posted Aug 12, 2015
  • Ghea Adeboyejo, MD

Chronic abnormal uterine bleeding is a problem that plagues 20% to 35% of women at some time in their lives, and generates 2.7 million office visits each year in the U.S. This chronic heavy or chronic prolonged vaginal bleeding exerts a heavy price in terms of quality of life, lost time from work and healthcare resources. Initial management usually begins with pharmaceutical treatment. While some patients are adequately treated with medical therapy, others may require or desire a longer acting, lower maintenance option. In the past, treatment options were limited and many women required a hysterectomy to control abnormal bleeding. While some cases of abnormal bleeding are still best treated with hysterectomy, newer minimally invasive procedures may offer women relief from chronic benign bleeding without long recovery times or the risks of surgery and general anesthesia.

Endometrial Ablation

Endometrial ablation is a minimally invasive option for the treatment of heavy or prolonged vaginal bleeding. The first generation non-resective endometrial ablation device was FDA-approved in 1997. Ablation of the endometrium is performed by inserting a device into the uterine cavity to uniformly destroy the uterine lining. The gynecologist can accomplish this with extremes of temperature—either heating or cooling.

There are currently five non-resective ablation devices available in the U.S. All of these devices reduce bleeding in 80% or more of women who undergo treatment. Once it is confirmed by biopsy that uterine bleeding is not due to endometrial malignancy, the gynecologist may select the most appropriate device for that patient. Uterine size and the size of any sub-mucosal fibroids are factors that affect device selection. The ability to perform endometrial ablation in an office setting offers the benefit of reduced patient costs, greater patient acceptability and ease of scheduling. All non-resective ablation procedures can be performed in the office setting under local anesthesia; however, cryoablation appears to be associated with the least pain during the procedure.


Cryoablation offers two distinct advantages over the heating modalities—decreased operative pain and the fact that it is performed under direct ultrasound guidance. A Heroption device cools the endometrial tissue to sub-zero temperature. This extreme cooling destroys the basal layer of the endometrium and causes numbness. Less operative pain allows us to perform cryoablations in the comfort of an office setting using only oral and local analgesics. In addition, the use of perioperative ultrasound helps to ensure complete ablation and avoid many complications.

Other methods of endometrial ablation use high heat, thus stimulating pain fibers and are therefore usually performed in the operative suite under general anesthesia. In addition, thermal ablations are not routinely performed with ultrasound assistance.

Benefits of Cryoablation

In-office endometrial cryoablation is a safe and effective treatment for benign, heavy or frequent uterine bleeding. Its advantages include avoidance of potential complications associated with general anesthesia or hysterectomy, less pain, and extremely short recovery time.

Recovery Time After Endometrial Ablation

Most patients are able to return to work in one to two days after endometrial ablation. In addition, most studies have shown an 85%-90% satisfaction with treatment after ablation. In one study, 30% of women reported no further periods, 39% reported scanty, infrequent periods, and 29% reported a return to normal light periods at one year follow up.

Dr. Adeboyejo is an OB/GYN with the Holy Cross Medical Group in Fort Lauderdale, FL. For referral information, call 954-900-6653.

Innovations in Neurosurgery: Providing Quality Care in South Florida

  • Posted Jul 20, 2015
  • Ali Jourabchi Ghods, MD

In this video, Dr. Ali Jourabchi Ghods, Neurosurgeon in the Holy Cross Neuroscience Institute, discusses how neurosurgery and the technologies involved in treatments of brain cancer and brain tumors have evolved over the years. Dr. Ghods compares Whole Brain Radiation Therapy and compares it with current treatment – Stereotactic Radiosurgery, which uses focused radiation during surgery. He also explains the O-Arm technology and Stealth Navigation and their benefits, which include less radiation and offers 3-D imaging and navigation that improve precision, accuracy, efficiency, and safety during surgery.  Dr. Ghods expresses the importance of being able to offer innovative treatments to ensure that patients do not have to seek quality care outside of their own community: 

Dr. Ali Jourabchi Ghods is a neurosurgeon who practices at Holy Cross Neuroscience Institute (Holy Cross Hospital) in Fort Lauderdale, FL. For referral information, call 954-900-6653.

The Fading Fad Diet

  • Posted Jun 29, 2015
  • David Zekser, MD

Many women feel forced to try to follow that strict, unyielding and frequently unhealthy short-term weightloss regimen that we lovingly know as THE DIET. The words bring regret and loathing to the minds of many women, like some disastrous relationship of the past. They might recall feeling jilted by all the fad diets they have loved and lost when the promise of miraculously stepping out of a pair of plus-size jeans into a bikini and high-heel shoes is replaced with the reality of modest weight loss, rapid regain and a sense of defeat.

The concept of the diet is outdated and redundant. A healthy weight is the byproduct of eating better, eating less of some foods and more of others, making better choices, consistency, and accepting the reality that a short-term solution will not solve a long-term problem. A few of the core concepts for weight loss that I find to be benefi cial and that I use in my own weight-loss program are:

Finding The Good MonsterSM

This relates to the concept of “damage control.” There will always be times when you are forced to eat the best option available, even if it is not a perfect one. If you are hungry and have 10 minutes to get to an appointment, you may have to choose between a slice of pizza, fast food places or not eating at all. Finding The Good MonsterSM means finding what works best for you in any situation and then moving forward while figuring out how to plan better meals and snacks.

Don’t expect a salad to fall out of the sky

Prepare in advance for busy times at work and leisure time at home by making good food choices more accessible and convenient than bad ones. It is just as easy to take the peel off a banana as a wrapper off a candy bar.

Cut back on the "bad" carbohydrates

This includes pasta, bread, rice and potatoes. Replace them with carbohydrates such as vegetables and fruit. Think about replacing food items instead of simply trying to eliminate them.

Think differently about dinner

Expectations of eating a big dinner or snacking before bedtime cause people to eat more at that time of the day simply out of habit, even when they are not hungry.

There are a lot of options for weight loss, but no matter what path you take to reach your goal, knowing how to stay there is the most crucial component to long-term success.

Dr. David Zekser is a primary care physician (Internal Medicine) practicing in the Rio Vista area of Fort Lauderdale. For referral information, please call 954-900-6653.

Contact Sports and Concussions (Part 2)

  • Posted Jun 22, 2015
  • Fernando Manalac, MD, MMM, CAQ...

If you missed “Part 1” of this post on how to prevent concussions, how they occur and symptoms  you may experience, you can read it here.

Concussion Management


Pre-Participation Evalutation (PPE): in my office, we conduct PPEs to establish a medical background from which medical decisions about physical activity may be made and medical clearance may be provided.

Baseline Testing: also available in my practice is a 20-minute computerized neurocognitive test (ImPACT testing) designed to measure the effects of concussion. After an athlete completes a baseline test, his or her data is stored on a secure, HIPAA compliant server. If a concussion is suspected in the future, a follow-up test is administered to see if the results have changed from the baseline. Traditional imaging procedures (CT or MRI) are helpful in identifying serious brain injuries, but they are not able to identify the functional effects of concussion. ImPACT can detect subtle changes in cognitive functioning that cannot be accurately measured by relying on athletes to report symptoms.

Other preseason testing include Maddox Questions (checks for memory), SAC (Standard Assessment of Concussion), BESS (Balance Error Scoring System); Sideline Concussion Assessment Tool (SCAT2); and NFL SCAT.


In addition to any necessary emergency response, the medical personnel on the field may perform various on-field and sideline assessments, such as a physical exam, neurocognitive and balance assessments, Neuropsychological (NP) Testing/Sideline Concussion Testing, and Return to Play evaluation.

At Home

• Dim/Quiet room

• Allow patient to sleep/rest!

• Very limited role of medications (OTC acetaminophen is most commonly prescribed)

• Seek medical attention if symptoms worsen acutely

Return to School/Play

Returning to school or play is a case by case management. Cognitive rest is needed – decreased concentration, reduced academic workloads, days off or shortened school days, extended test taking times and return to full academics when symptom-free. There should also be a progressive return to play: crawl -> walk -> run -> practice -> play. Talk to your doctor about treatments based on symptoms, age and medical history.

Before returning to school or play, there must be a medical clearance, be symptom-free, not taking medications and there must be a return to baseline based on the neurocognitive / physical / balance exams.

Keep in mind that a premature return to play can lead to a more severe concussion/prolonged symptoms. “Second Impact” syndrome is a second episode of brain trauma before the brain heals from the first. Cerebral arteries lose their ability to autoregulate (vasoconstrict), resulting in diffuse brain swelling/increased intracranial pressure. Second Impact syndrome involves a high incidence of brain herniation, coma and/or death.

Chronic Traumatic Encephalopathy

This condition is known in boxing as Dementia Pugilistica or Punch-Drunk Syndrome. It’s a progressive degeneration of the brain secondary to multiple brain injuries (concussions). Symptoms involve a change in mood (depression/suicidal ideation), cognition (memory loss), movement (parkinsonianism/balance dysfunction) and behavior (aggression).

Protect Yourself

Before engaging in activities or sports in which head injuries are common (football, soccer, basketball, volleyball, baseball, hockey, etc.), consult with a sports medicine physician regarding how to prevent head injuries, your risks for concussion, a PPE, and baseline testing to be proactive in managing possible concussions.

Dr. Fernando Manalac is a board certified sports medicine physician who practices at the Holy Cross Orthopedic Institute in Fort Lauderdale, FL. For referral information, call 954-900-6653.

Why Do My Shins Hurt When I Run?

  • Posted Jun 16, 2015
  • John Angus, MS, ATC

Marathon Runners

Running is a popular exercise; we are running more frequently and for longer distances than we ever have, so we’re seeing an increase in lower leg injuries. Many people have pain on the inside of their lower legs that they classify as “shin splints.” Although shin splints are common, this may not be the correct diagnosis for the cause of your pain. There are many different structures that can succumb to overuse injuries including bone, muscle, tendon, fascia or some combination. Some of the more common injuries experienced in the lower leg are medial tibial stress syndrome, tibial stress fractures and tibialis posterior tendonitis/dysfunction. All of these conditions tend to appear in very close physical proximity, but each should be managed differently.

What are the differences?
Medial Tibial Stress Syndrome (MTSS) is a repetitive stress injury that is commonly correlated with the term shin splints. People that experience MTSS are usually doing something different with their activity like starting a new workout regimen, increasing workouts too rapidly or changing another aspect (shoes, surfaces, etc.). The etiology of the injury is still somewhat debated, but most experts believe that the end result is a combination of tendonitis, stress reaction of the tibia, and periostitis (inflammation of the connective tissue lining the bone).

Athletes continuing to push through the pain without modification or those increasing their activity can increase the likelihood of a tibial stress fracture (TSF).  This is a more advanced version of MTSS that will have a raised portion of the lining of the bone or fracture lines within the bone.

A third common condition - Tibialis posterior tendonitis/dysfunction (TPT) - can increase the risk of developing MTSS and TSF but can also be found as a problem on its own. The tibialis posterior muscle attaches under the foot to help support your arch and helps to plantar flex the foot while running. Fatiguing as you run puts more stress along this tendon which leads to dysfunction and inflammation.  The pain can run anywhere along the muscle from the calf, inside aspect of the lower leg, and/or under the foot.

What do I do?
Prevent the injury from occurring with a smart training regimen that does not increase loads too quickly. The best treatment once MTSS has set in is rest or a few weeks of activity modification. Some people use orthotics to reduce excessive pronation and perform ankle-strengthening exercises.  If the condition worsens to TSF, a cast or boot is needed and non-weight bearing until the fracture heals.  TPT can be treated with RICE (Rest, Ice, Compression and Elevation), but a good physical therapy regimen for ankle and foot strengthening can speed up the healing. Orthotics may also help to relieve pain and dysfunction until the tendon can return to normal activity. These are not the only lower leg conditions you may experience with running, especially if you have other symptoms; therefore, a good physical exam and history is always needed to tease out the diagnosis and get you back to your normal activities as fast and safely as possible.

John Angus, MS, ATC, is an Athletic Trainer practicing at the Holy Cross Orthopedic Institute in Fort Lauderdale, FL who works closely with our Holy Cross Medical Group sports medicine specialist. For physician referral information to a sports medicine specialist, call 954-900-6653.

Contact Sports and Concussions (Part 1)

  • Posted Jun 09, 2015
  • Fernando Manalac, MD, MMM, CAQ...

Dr. Manalac with nurse in helmet at concussion lectureContact sports like American football have long been known for brutal head injuries. As much education that our athletes still need today, we have come a long way since the sport’s origins in the 1860s - when the world lacked understanding of concussions and how to care for those with such head injuries. Over the years we have gained a much better understanding of the pathophysiology of concussions, symptoms, management, and more importantly, how to prevent the injury.


How Concussion Occurs

A concussion is caused when there is impact from which the brain shifts within the cerebrospinal fluid and strikes the skull, causing direct injury. The brain then whips back and strikes the opposite side of the skull. Commonly, there are rotational components to the force, which cause “twisting” of the brainstem and is associated with loss of consciousness. Microscopically there is shearing of the axons in the brain and excessive release of neurotransmitters - the brain’s attempt to start repairing itself or reach homeostasis. This is when you will experience a huge imbalance of energy supply and demand needed for recovery. It is also during this time that the brain is most vulnerable to a “Second Impact.”

Preventing Concussions

My patients and their family members may be surprised to know that protective equipment has not shown to reduce the number of concussions. Direct head trauma is not necessary to develop concussion; any impact that causes the brain to strike the skull or a rotation of the brain stem can cause a concussion. Neck strengthening programs may help in theory, but no studies have been done at this time. Limiting contact / cutting down on the number of contact practices has been shown to reduce concussions. Player behavior modification can help to prevent this head injury – educate players, coaches and trainers and adjust the rules to ensure proper technique and injury management.


If you do suffer from a concussion, the most commonly reported symptom is headache. Dizziness and nausea / vomiting may also occur, as well as visual disturbance. Cognitively, there may be memory loss, some have decreased concentration, confusion, and loss of consciousness. You may also experience emotional symptoms such as irritability, depression and anger. It is also common to feel drowsy or tired and have difficulty sleeping (insomnia). It is important to know, however, that with all possible symptoms, it only takes one symptom to constitute a concussion after a head injury.

Check back for Part 2 of this post for details on concussion management.

Dr. Fernando Manalac is a board certified sports medicine physician who practices at the Holy Cross Orthopedic Institute in Fort Lauderdale, FL. For physician referral information, call 954-900-6653.


About Holy Cross Hospital

Holy Cross Hospital is a nonprofit, Catholic hospital in Fort Lauderdale, Florida, dedicated to innovative, high quality and compassionate care. For nearly six decades, Holy Cross has continuously expanded its services to provide leading-edge care for their patients in Florida and for those from elsewhere in the United States. Holy Cross also offers an International Services program to ensure that patients from outside the U.S. receive the care they need.

Blog Categories

Blog Archive