In the operating room with Dr. Gustavo Gaspar Blanco


Dr. Gustavo Gaspar, plastic surgeon

Dr. Gustavo Gaspar, plastic surgeon

In the operating room with Dr. Gustavo Gaspar Blanco

Hospital de la Familia,

Mexicali, B.C.

Mexico

After interviewing Dr. Gaspar, he graciously invited me to join him in the operating room as an observer for several cases during the week.

Hospital de la Familia

As reviewed in the Mexicali! mini-guide to medical tourism, Hospital de la Familia is widely acknowledged as “the second best hospital in Mexicali.”  Much like the Hertz automobile rental campaign “We try harder,” the directors of Hospital de la Familia have embarked on an aggressive publicity campaign to attract patients and physicians to their facility.  This includes medical tourism – as Hospital de la Familia has partnerships with multiple brokers including PlacidWay and Planet Hospital.

Dr. Gaspar exclusively operates at Hospital de la Familia.

In the ORs at Hospital de la Familia

OR #3 is the plastic surgery suite.  It is spacious and well-lit with modern and functional equipment.  Along with a designated OR, Dr. Gaspar has an operating room team consisting of an anesthesiologist, an assistant surgeon, scrub nurse and circulating nurse.

Dr. Gaspar and his OR team

Dr. Gaspar and his OR team

Anesthesia is managed by Dr. Armando Gonzalez Alvarez.  He monitors the patient with due diligence and remains in attendance at all times.  He avoids distractions during surgery (like texting or excessive cell phone use) and remains patient-focused.

Dr. Gonzalez Alvarez, Anesthesiologist

Dr. Gonzalez Alvarez, Anesthesiologist

Dr. Binicio Leon Cruz, is a general surgeon who serves as Dr. Gaspar’s assistant surgeon during the case.  Monica Petrix Bustamante is the instrumentadora (scrub nurse), and she is excellent, as always*. She knows the surgeries, easily anticipates the doctors’ needs while maintaining surgical sterility and ensuring patient safety.

Monica prepares a prosthesis for implantation

Monica prepares a prosthesis for implantation

Adherence to international protocols

The majority of procedures are under an hour in length, which means that patients do not need deep vein prophylaxis during surgery.  The procedure (including site) and patient identity are confirmed prior to surgery with active patient participation before the patient receives anesthesia with both surgeons, nursing staff and the anesthesiologist in attendance.  Patients are then prepped and draped in sterile fashion, with care taken to prevent patient injury.

As with many plastic surgeons, Dr. Gaspar does not administer IV antibiotics for infection prophylaxis prior to the first incision.  Instead, all patients receive a course of oral antibiotics after surgery***.

Surgical sterility is maintained throughout surgery.  For the first case, after receiving adequate tissue preparation, since only limited liposuction is needed (for very specific sculpting), the patient receives manual liposuction (without suction) to prevent overcorrection or excess fat removal.  Despite having significant adhesions due to previous liposuction procedures, there is very minimal bleeding during the procedure.

Following the procedure, the patient is awakened, extubated and transferred to the recovery room for hemodynamic monitoring and adequate recovery prior to discharge.

Throughout the case, (and during all subsequent checks in the PACU), the patient is hemodynamically stable, and maintains excellent oxygenation.

The second case, is a breast augmentation revision – in a patient with a previous breast reconstruction after mastectomy for breast cancer.  The patient developed a capsular contracture which required surgical revision**.

Abdominoplasty

On a separate occasion, Dr. Gustavo Gaspar performed an abdominoplasty with minor liposuction of the “saddle bag” area at the top of the thighs.  For the abdominoplasty case, the patient received conscious sedation with spinal anesthesia.

While an abdominoplasty, “tummy tuck” is a much larger procedure, the case proceeded quickly (1 hour 15 minutes), and uneventfully.  There was very minimal bleeding, and excellent cosmetic results.

skin, and adipose tissue removed during abdominoplasty.

skin, and adipose tissue removed during an abdominoplasty

Gluteal augmentation (Gluteoplasty)

However, it was the gluteal augmentation case that attracted the most interest.  As mentioned during a previous interview, Dr. Gaspar is well-known throughout Mexico for his gluteal implantation technique.

Pre-surgical planning

Pre-surgical planning

Due to the proximity to the anus, and potential for wound infection and contamination, the area is prepped in a multi-step process, in addition to the standard surgical scrub.  A Xoban (iodine impregnated dressing) is applied to the area to prevent bacterial migration to the area around the incision.

For this procedure, Dr. Gaspar uses gluteal prostheses for intramuscular implantation.  Using one, small 3 cm incision, Dr. Gaspar dissects through the gluteal tissue to the muscle plane.  He then inserts the prosthesis and adjusts it into its final position.  When he has finished placing the implant, it is buried deep in the tissue and invisible.

after the implant is placed within the muscle it is invisible to the eye

after the implant is placed within the muscle it is invisible to the eye

He explains that by placing the prostheses in the intramuscular layer, the implants remain in a stable position, and are invisible to the eye and imperceptible to the touch.  (Even with movement and manipulation – there is no edge or pocket seen or felt after the gluteal prosthesis is placed).

The procedure is repeated on the opposite side.  Two small drains are placed, and the incision is closed.  The entire procedure has taken just 18 minutes.

incision and drains at the conclusion of surgery

incision and drains at the conclusion of surgery

Despite the speed by which Dr. Gaspar operates, he is meticulous in his approach. He frequently re-assesses during the procedure (particularly during bilateral procedures) to ensure symmetry of results.

*I frequently encountered Ms. Petrix during previous visits to the operating rooms at Hospital de la Familia during research and writing of the Mexicali book).

** Capsular contraction is one of the most frequently occurring complications of breast augmentation using breast prosthesis (implants).

*** this practice is somewhat controversial but the most recent surgical guidelines and literature on antibiotic stewardship suggest that pre-operative antibiotics may be unnecessary for some surgical procedures.

Thank you to the kind patient who graciously gave permission for publication of pre-operative, intra-operative and post-operative photographs on this site.

Additional readings: Gluteoplasty

The majority of publications originate in Latin America and Latin American journals (and are written in Spanish and Portuguese.)  Here is a small selection of open-access, English language journals.

Bruner, T. W., Roberts, T. L. & Nguyen, K. (2006).  Complications of buttocks augmentation: Diagnosis, management and prevention.  Clin Plastic Surg 33: 449 – 466.

Cardenas – Camarena, L. (2005). Various surgical techniques for improving body contour.  Aesth. Plast. Surg. 29:446-455.

Cardenas- Camerena, L. & Palliet, J. C. (2007).  Combined gluteoplasty: Liposuction and gluteal implants.  PRS Journal, 119(3): 1067 – 1074.  Part of a series on gluteal augmentation.

Harrison, D. & Selvaggi, G. (2006). Gluteal augmentation surgery: indications and surgical management.  JPRAS 60:922-928.

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Spending the day with Dr. Gabriel Ramos, Oncology Surgeon


Spent the day in the operating rooms with one of my favorite Mexican surgeons, Dr. Gabriel Ramos Orozco.  Dr. Ramos is an oncology surgeon with offices in Mexicali (Baja California) and his hometown of San Luis Rio del Colorado in Sonora, Mexico.

Dr. Gabriel Ramos Orozco, Oncology Surgeon

Dr. Gabriel Ramos Orozco, Oncology Surgeon

In the operating room with Dr. Gabriel Ramos

We spent the day in his hometown – first at the Hospital Santa Margarita, where he performed a laparoscopic cholecystectomy, and then in his offices seeing patients.

In the operating room

In the operating room – photos edited to preserve patient privacy

Hospital Santa Marta

The hospital itself was a small intimate clinic.  The operating rooms were small but well-equipped.  We were joined by Dr. Campa, an excellent anesthesiologist and another general surgeon.  While the anesthesia equipment was dated, all of the equipment was functional.  At one point, the sensors for cardiac monitoring and oxymetry readings malfunctioned but within seconds a backup monitor was attached.  (This is a frequent occurrence in most hospitals around the world and the USA because the sensors that connect to the patient with gel are cheap disposable and somewhat fragile.)

There were several monitors dedicated to laparoscopy with good display quality.  The operating rooms had ample light and functioned well. Overall the clinic was very clean.

ramos surgery

The surgery itself proceeded in classic fashion.  The patient was positioned appropriately and safely before being prepped and draped in sterile fashion.  Since the surgery itself was of short duration, anti-embolic / DVT prophylaxis was not required but was still applied.  (Note:  in Mexico, these stockings are of limited utility – and for more lengthy procedures, TEDS or electronic squeezing devices are usually applied.)

The surgery itself was under an hour, with no bleeding or other complications. The patient was then transferred to the post-operative care area for monitored recovery from general anesthesia.

Dr. Ramos performs laparoscopic surgery

Dr. Ramos performs laparoscopic surgery

In the clinic

It was an interesting day – because he sees a diverse mix of patients.  As a general surgeon, he also operates for many of the classic indications, so there were several patients who saw Dr. Ramos for post-operative visits after appendectomies, cholecystomies (gallbladder removal) and the like.  There was also a mix of patients with more serious conditions like colon, testicular and breast cancers.  His patients were a cross section of people, from the United States and Mexico alike.

International patients

Some of these patients came for the lower cost of treatment here in Mexico, but others came due to the dearth of specialty physicians like oncology surgeons in places like Yuma and Las Vegas.  Many of these international patients spoke Spanish, or brought translators with them since Dr. Ramos is primarily Spanish speaking.

Since D. Ramos is not well-known outside of Mexico, many of these patients were referred by word-of-mouth, by former patients, friends and family.

Then it was back to the hospital twice to visit his patient post-operative.  She was resting comfortably and doing well.  It is this level of service that draws patients to his clinic both here and in central Mexicali.

This winter, Dr. Ramos returns to school so to speak – as he will be spending several months in Barcelona, Spain and Colombia learning new techniques such as uni-port laparoscopy.  He will then be able to offer these state-of-the-art treatments to his patients back here at home; whether these patients come from northern Mexico or other parts of the globe.

Highly Recommended:  Excellent surgeon with well-coordinated team.  However, patients requiring more extensive surgery (large tumor surgeries/ cytoreductive surgery) should request Dr. Ramos perform surgery in the larger Mexicali facilities for better access to advanced and specialized support services like hemodialysis etc. for sicker/ higher risk patients. 

However, the level of care was appropriate at this facility for this procedure, which is rated as low-risk.  (i.e. generally healthy patient, with straight-forward procedure)

Dr. Horacio Ham, and Los Doctores


Just finished interviewing Dr. Horacio Ham, a bariatric surgeon with the DOCS (Diabetes & Obesity Control Surgery) Center here in Mexicali.  Later this evening, we’ll be heading off to surgery, so I can see what he does first-hand.

Tomorrow sounds like a jam-packed day for the young doctor, he’s being interviewed for a University television series on Obesity in addition to his normal activities (surgery, patients) and of course, the radio show.  Turns out his guest doctor tomorrow evening is none other my professor, the ‘good doctor.’

Sounds like a great show – so if you are interested it’s on 104.9 FM (and has internet streaming) at 8 pm tomorrow night..

I’ll report back on the OR in my next post..

In the operating room with Dr. Carlos Ochoa, thoracic surgeon


Mexicali, Baja California (Mexico)

Dr. Carlos Cesar Ochoa Gaxiola, Thoracic Surgeon

We’ve back in the city of Mexicali on the California – Mexico border to interview Dr. Carlos Cesar Ochoa Gaxiola as part of the first of a planned series of video casts.   You may remember Dr. Ochoa from our first encounter back in November 2011.  He’s the personable, friendly thoracic surgeon for this city of approximately 900,000 residents.  At that time, we talked with Dr. Ochoa about his love for thoracic surgery, and what he’s seen in his local practice since moving to Mexicali after finishing his training just over a year & a half ago.

Now we’ve returned to spend more time with Dr. Ochoa; to see his practice and more of his day-to-day life in Mexicali as the sole thoracic surgeon.  We’re also planning to talk to Dr. Ochoa about medical tourism, and what potential patients need to know before coming to Mexicali. He greets me with the standard kiss on the cheek and a smile, before saying “Listo?  Let’s go!”  We’re off and running for the rest of the afternoon and far into the night.  Our first stop is to see several patients at Hospital Alamater, and then the operating room for a VATS procedure.

He is joined in the operating room by Dr. Cuauhtemoc Vasquez, the newest and only full-time cardiac surgeon in Mexicali.  They frequently work together during cases.  In fact, that morning, Dr. Ochoa assisted in two cases with Dr. Vasquez, a combined coronary bypass/ mitral valve replacement case and a an aortic valve replacement.

Of course, I took the opportunity to speak with Dr. Vasquez at length as well, as he was a bit of a captive audience.  At 32, he is just beginning his career as a cardiac surgeon, here in Mexicali.  He is experiencing his first frustrations as well; working in the first full-time cardiac surgery program in the city, which is still in its infancy, and at times there is a shortage of cases[1].  This doesn’t curb his enthusiasm for surgery, however and we spend several minutes discussing several current issues in cardiology and cardiac surgery.  He is well informed and a good conversationalist[2] as we debate recent developments such as TAVI, carotid stenting and other quasi-surgical procedures and long-term outcomes.

We also discuss the costs of health care in Mexicali in comparison to care just a few short kilometers north, in California.   He estimates that the total cost of bypass surgery (including hospital stay) in Mexicali is just $4500 – 5000 (US dollars).  As readers know, the total cost of an uncomplicated bypass surgery in the USA often exceeds $100,000.

Hmm.. Looks like I may have to investigate Dr. Vasquez’s operating room on a subsequent visit – so I can report back to readers here.  But for now, we return to the case at hand, and Dr. Ochoa.

The Hospital Alamater is the most exclusive private hospital in the city, and it shows.   Sparkling marble tile greets visitors, and patients enjoy attractive- appearing (and quiet!) private rooms.  The entire hospital is very clean, and nursing staff wears the formal pressed white scrub uniforms, with the supervisory nurse wearing the nursing cap of yesteryear with special modifications to comply with sanitary requirements of today.

The operating rooms are modern and well-lit.  Anesthesia equipment is new, and fully functional.  The anesthesiologist is in attendance at all times[3].  The hemodynamic monitors are visible to the surgeon at all times, and none of the essential alarms have been silenced or altered.  The anesthesiologist demonstrates ease and skill at using a double lumen ETT for intubation, which in my experience as an observer, is in itself, impressive.  (You would be surprised by how often problems with dual lumen ETT intubation delays surgery.)

Surgical staff complete comprehensive surgical scrubs and surgical sterility is maintained during the case.  The patient is well-scrubbed in preparation for surgery with a betadine solution after being positioned safely and correctly to prevent intra-operative injury or tissue damage.  Then the patient is draped appropriately.

The anesthesiologist places a thoracic epidural prior to the initiation of the case for post-operative pain control[4].  The video equipment for the case is modern with a large viewing screen.  All the ports are complete, and the thoracoscope is new and fully functioning.

Dr. Ochoa demonstrates excellent surgical skill and the case (VATS with wedge resection and pleural biopsy) proceeds easily, without incident.  The patient is hemodynamically stable during the entire case with minimal blood loss.

Following surgery, the patient is transferred to the PACU (previously called the recovery room) for a post-operative chest radiograph.  Dr. Ochoa re-evaluates the patient in the PACU before we leave the hospital and proceed to our next stop.

Recommended.  Surgical Apgar: 8


[1] There is another cardiac surgeon from Tijuana who sees patients in her clinic in Mexicali prior to sending patients to Tijuana, a larger city in the state of Baja California.  As the Mexicali surgery program is just a few months old, many potential patients are unaware of its existence.

[2] ‘Bypass surgery’ is an abbreviation for coronary artery bypass grafting (CABG) aka ‘open-heart surgery.’  A ‘triple’ or ‘quadruple’ bypass refers to the number of bypass grafts placed during the procedure.

[3] If you have read any of my previous publications, you will know that this is NOT always the case, and I have witnessed several cases (at other locations) of unattended anesthesia during surgery, or the use poorly functioning out-dated equipment.

[4] During a later visit with the patient, the patient reported excellent analgesia (pain relief) with the epidural and minimal adjuvant anti-inflammatories.

Welcome to Mexicali!


As I mentioned in a previous post – here at Cartagena Surgery, we’ve decided to explore some of the border cities of our neighbor to the south, Mexico.  For many people,  Mexico is the most practical option when it comes to medical tourism.

For our first look at Mexico, we’ve decided to travel to Mexicali, in Baja, California.  It’s just across the border from Calexico, California and is home to around one million people – making it a large metropolitan area.

With the drastic increase in drug-related crime and killings plaguing many of the other cities in Mexico such as Cuidad Juarez “Murder capital of the world,”  Tijuana and even the smaller Nogales, Mexicali is the safer, sweeter option for border cities.

In fact, Mexicali is known as the most affluent of cities in Baja California – and it is certainly apparent during our visit due to the availability of a wide range of medical services.  While the entry from the central border gate leads to a bustling commercial district, the more upscale, attractive residential neighborhoods are only a fifteen minute walk from the border.

At the Mexicali - Calexico border

About Mexicali:

Travel and Tourism links for Mexicali:

Official Mexicali tourism page – has English version. Also has a health section promoting local physicians and hospitals.

Mexico Tourism Information

WikiTravel

Getting Here:

The easiest way to get for (for many people) is to walk.  After driving to Calexico, California – turn down Imperial Boulevard and head towards the border.  Turn right on second street – and cross the railroad tracks.  Immediately on the left – there is a secured parking lot.  It costs about three dollars to park here overnight.

Take your valuables with you – and as you leave, proceed back down second street towards Imperial.  Cross Imperial – and walk about two more blocks.   Turn left on Rockland, and proceed towards the Calexico government building.  On the front of the building – you will see a set of turnstiles (like at an amusement park.)  Walk through the turnstiles – walk another 40 feet to the second set of turnstiles – and you are now in Mexico..

the doorway to Mexico

You will then walk through a short underground causeway – filled with little shops, and money changers/ cambios.  (This is one of the better places to change money – the rates are surprisingly competitive, and beat anything on the American side.)  When you emerge from the short hallway – there are stairs on the left.

These stairs lead to one of the main streets in Mexicali for medical services – Maduro.

Update: March 2012

I will be living in Mexicali for several months – so look for more postings and information about medical tourism/ medical services in Mexicali in the future.