An Interview with Dr. Gustavo Carvalho, Bariatric Surgeon, Universidade de Pernambuco

HI Sarah, at first I’d like to say thank you, it is for me not only great honor but a great pleasure to work with you again in this interview, and I hope I can be of some help not only to give my sincere opinion but also to share my enthusiasm about Minilaparoscopy, that is possibly one of the most sub used great technique of minimally invasive surgery.

1. What is unique about the development of the new "mini-lap"?

 The low friction trocars were really a game changer for us, allowing us to tie knots and dissect tissue with an unmatched precision. Current Mini trocars we are using now, is called low friction, and unlike their ancestors from the 90s, do not have a sealing membrane or a valve (Low Friction). They have very low friction between trocar and forceps, therefore almost no force is needed to move the instruments inside the trocars. The possible increase in CO2leak was a huge reason for criticism at that time, but actually we measured ii, and it is so small – less than 0.1 l/min - that it does not impose any real consequence in the performance of the procedure. Its also nice to observe that many current technical limitations of MINI are being resolved by the efforts of the industry in crafting more resistant, with less chance to bend and higher performance instruments. The second point that we must stress about our new mini technique is that we have almost no use for the mini 3mm optics, especially for doing routine cases like cholecytectomies and inguinal hernias. For the third point we must not forget the fact that there are no 3mm clip appliers or stapling devices for mini. To solve this limitation, we have been always emphasizing the importance of the correct use of monopolar and bipolar electrosurgery, as well as the use of intracorporeal knots. Several procedures like appendectomy, inguinal hernia repair, anti-reflux procedures and of course our killer procedure mini-cholecystectomy are really suitable for the mini technique that we call clipless – it is overall much simpler and most efficient than the regular mini, that imposes a need to change optics in order to place clips - as we do not use the mini optics and consequently we can’t and don’t need to exchange the scope from 10 to 3mm and vice-versa just to put clips in the cystic duct and cystic artery - changing optics makes the procedure not only boring and time consuming but also more expensive as the mini-optics are expensive and not really long living. Mini clipless has been a real advancement for us. Wehave been performing this technique of Clipless cholecystectomy since 2000 and for that we have used just a standard 10-mm scope, we have been following very rigid standard principles, and after 16 years of experience we have done over 2.100 MINI Clipless cholecystectomies, without mortality, significant hemorrhage, cbd injuries or conversion to open surgery, when necessary, in few cases we have converted to regular laparoscopy – by placing 1 to 3 5mm trocars – that can undoubtedly confirm the safety of the mini clipless procedure. Currently, MINI Clipless is, depending on the settings, an ambulatorial procedure or a 1-day surgery, very safe, with all the advantages of laparoscopy, highly reproducible, cost effective, and with great aesthetic appeal leading to highly satisfied patient !

2.      How is it different from the old mini lap?

Ok Sarah, for that question let me take as an example the case of mini-clipless cholecystectomy: besides the fact that we use low friction trocars, what gives us much better dexterity and make our knot tying easier and quicker, not only when compared with regular laparoscopy but also when we compare it with the minis with regular trocars, we also have the advantage use a totally new generation of mini instruments, longer, much better crafted and with much stronger and durable material, when we compare them with the old instruments from the 90’s.

Still there are 5 points that must be emphasized in our technique that makes it a really simple and standard procedure, now being reproduced in several countries around the world.

1) Only one 11mm Trocar is used and its scar is hidden inside the navel, three other low friction mini-ports are used for inserting mini instruments.

2) As only one 10mm optics is used there is no necessity for boring and time consuming 3mm optics exchange, therefore we must tie knots.

3) Cystic duct is securely closed with surgical knots

4) Cystic Artery is safely sealed by electrocautery, strict principles must be followed for safe cauterization of cystic artery.

5) Gallbladder is always retrieved in a BAG, increasing safety for preventing contamination of the umbilical wound, also avoiding the necessity to exchange the optics.  

Considering that NOTES cholecystectomy is still experimental, although hybrid transvaginal cholecystectomy is gaining popularity in clinical practice and single port is still a nonstandard approach, with significant technical challenges, and a not stablished safety profile, Mini´s approach almost identical to the standard laparoscopic technique offers significant benefits without exposing patients to unecessary postoperative complications, therefore being the logical choice of evolution for a routine elective cholecystectomy.

3.      How do you think your new development will impact mini lap as it becomes more established in the industry?

In the last few years, mini has evolved from a mere surgical curiosity to a really useful and advantageous technique, and is currently being used more and more in many center around the world to perform a wide variety of surgical procedures in different surgical areas, such as colorectal, gynecologic, pediatric, urologic and general surgery, always in a safe and reproducible manner. The transition from traditional laparoscopy to Mini is really very smooth and easy for the general surgeon who is already well trained in laparoscopy. There is still however, a need to get familiarized with the mini-instruments and to learn some tips and tricks, for that, to supply that training, industry can be really helpful, as an untrained surgeon can jeopardize the technique for not using the instruments in the correct way, possibly damaging the instruments and the patient.

Another aspect that is important to mention is that mini is a cost saving procedure, Since low-friction mini-trocars and other mini instruments are reusable and now long lasting, Mini can lead to a significant cost reduction, since the high cost use of disposable equipment is avoided. On the other hand, the burden of clip appliers and staplers not existing for Mini procedures, reduces even more the total cost of different procedures. In the specific case ofcholecystectomy, not using clips not only saves money, but also surgical time since scope exchange is not necessary. In the case of inguinal hernia TEP repair, no balloon dissection is used and Mini-TEP is considerably faster compared to regular laparoscopic TEP repair. In mini appendectomy a knot is easily tied at the base, and no staplers are needed to be used in most of the cases. Staplers and clips are costly equipment, mini procedures, in general, do not use them, the advantages in cost effectiveness of mini procedures have been reported in surgical literature for different procedures calling the attention a paper published by Chekan at JSLS in 2013 when he found that mini cholecystectomy is more than 200 dollars cheaper than an average laparoscopic conventional chole. Considering that over 700.000 lap-choles are performed every year in USA, the adoption of mini besides all the advantages for the patients would imply in an economy of at least 140.000.000 USD, and those cases were not clipless, imagine if those cases could have been done clipless the economy would possibly be even higher.

4.      What do you see is the future for mini lap?

Even though mini has been among us for more than 20 years, we must say that the game is just starting for mini now, we believe in a bright future for mini in a not very long time from now. Unlike other new access methods like NOTES, Robotics and single-port, MINI reigns for its simplicity, offering increased dexterity, delicacy, and precision, without significantly adding extra costs and at the same time, maintaining the triangulation that is already an important stablished advantage of standard laparoscopy. As surgeons we all know that surgical precision has always been dear to our hearts. All those new developments will have a huge impact on mini as it will be progressively more standard and widespread as an efficient and cost effective surgical tool. Mini is more and more occupying the space that would in the long run be occupied by robots, but because of money shortage, that space is being occupied by minis. We will see from now, more and more, the most critical parts of a complicated laparoscopic procedure being done by minis, like a cbd exploration or reconstruction after a biliary procedure, or pyeloplasty, or a ureteral reconstruction, or tubal anastomosis, and believe me cosmetics will not be the reason, but true reason will be to use the proper instrument for the proper task. Imagine that a small needle for a 5-0 or 6-0 thread is better handled by a 3.0mm needle holder than with a 5mm needle holder. The surgeon who performs open surgery do not use the same instrument for different scale tasks. When they close the abdomen, which is a brutal task they use bigger and stronger needle holder and forceps, but when they are performing a very delicate anastomosis like a cbd or vascular suturing they switch theirs instruments for more delicate and proper ones. Why an endoscopic-surgeon must use only 5mm and 10mm instruments during a whole lap procedure. We believe that in a near future for example during a pacreatoduodenectomy a surgeon will switch to a robot to perform the more delicate anastomosis in a much more precise way, but for the surgeon who do not have enough resources to invest in a robot, still he will have the choice to do better by using mini instruments. In the long run mini would be considered the poor man robot. In the near future mini will be recognized not only as a tool with cosmetic advantages but with all the real advantages: besides being a simple and standard procedure, it gives the patient much less wall damage, is cost effective, have improved visualization and dexterity, keeping a safety profile compatible to standard laparoscopy, all those advantages that mini can provide goes far beyond cosmesis, the only proven advantage of single port so far!

5.      What other new things are you working on?

Most of our new plans now includes the development of new mini tools, and applying mini in even more advanced procedures, that will make mini even more attractive. Also we are pushing mini to the limits, doing now all advanced surgeries and procedures that we believe are much better performed by mini than regular LAP. We are now also working very hard in sending the mini message to the world, so more surgeons around the world will be able to understand that mini has much more to offer than just a pretty face, and cosmesis is just a good side effect of mini. When surgeons are able to understand that message they will be able to enjoy the real benefits of mini. We are also collaborating with many important surgical societies, like SOBRACIL, SLS and ELSA among others. We also are trying very hard to keep mini on the media and to make it even more attractive for surgeons and patients. We have recently started a facebook group named mini friends, and so far it is a great success being accessed regularly by more than 2300 surgeons around the world, who are interested in minimally invasive surgery, very interesting discussions including videos, pictures, questionings and case reports are being discussed frequently there, and for that we believe facebook is an amazing tool. We believe mini is now mature, but the real message of mini still need to be spoken and for that we once more thank you SARAH for the opportunity!

Gustavo Carvalho, M.D., is a laparoscopic/bariatric surgeon in Recife, Brazil, with subspecialties in minimally invasive surgery. He is a Society of Laparoendoscopic Surgeons (SLS) faculty member and recognized as a pioneer in mini-laparoscopy.

Why I Target Newspapers To Reach Sophisticated Client Audiences

By Sarah Sherwood, publicist

Let’s face it:  The power of news coverage not only names you, but helps define your company.  We know the competition for news coverage is fierce for our client’s target audience.  The American attention span has changed, but hunger for good information hasn’t.  To be sure, traditional news remains an important part of public life. More than seven-in-ten U.S. adults follow national and local news somewhat or very closely and 65% follow international news with the same regularity.[1]  For those who pay attention and crave news – a key audience for most clients – it’s a jungle out there.  But there are specific strategies that help you get through.

Today specific targeting of communications is more crucial, period.  Even in 2017 there are many, many targets, of great variety.  But don’t be fooled—there are too many outlets that are not well read and/or do not have much credibility and they are a waste of your time and money. Smarter targeting involves first knowing your audience well, including which sources they’re really getting their news from so your communications staff can focus on primarily delivering to those traditional and digital media outlets, third party organizations and potential partners that will garner results and meet goals. Even though there are fewer traditional media outlets, my experience tells me that if you are targeting a more sophisticated audience, there are more results with traditional news media coverage because traditional news still carries more weight. And my money is on newspapers, both in digital, and yes, paper form.

The Established, the higher-middle class to the upper crust audience, engage with and trust print advertising over digital media. In fact, research shows that print advertising in newspapers ranked the highest among millionaires, in their engagement potential, at a high of 74 percent.[2]  Why?  Generally speaking, these are the people who have the patience to engage for a longer amount of time, and are impressed when the content moves them (because they tend to be more passionate).  They tend to have higher levels of emotional intellect, which translates into a real reader.  They tend to live in one place longer, which hints at stability.[3]

It is true that overall Americans distrust in news outlets is growing, among mostly younger audiences and some have stopped reading newspapers all together.  But again, don’t be fooled.  If you are targeting a sophisticated reader, one with more experience, education and income (generally speaking), these are newspaper readers. For the average Daily reader, who has spending and decision-making power, trust in the media has declined only marginally, according to Pew research.  These are Americans who decry lower standards of journalism, such as opinion-driven writing and outlets with less rigorous reporting criteria.  So while you are pleased that your marketing materials are out there on social media sites, don’t be too pleased, because it doesn’t tend to work with a sophisticated audience.  Overall numbers do not matter—it is who is viewing your advertisement or news story that is important.  With social media, with the exception of a few, it’s easier to click through and off.

In contrast, newspapers have a highly dependable audience.

Digital newspaper readership, however, is growing, and will grow out of its adolescence as newspapers continue to figure out how we like to consume its information.  Social media is showing pretty low confidence scores[4], and my experience is that in general (there are real exceptions), it can be pretty tough to sell to a customer via social media, as opposed to digital news, although your best bet is to have an integrated marketing and publicity campaign that will both persuade and tell your publics where to go. Just know that your readers will see social media information as advertisements rather than news[5].  Even with younger readers, you want more recognizable news brands, with a history of accuracy, in order to persuade.[6]

The fact is that newspaper readership is mostly made up of an established, stable, more educated and higher income audience, which is critical to your sophisticated campaign. 

So why aren’t more communications departments going after publicity and publicity targeted toward newspapers? Marketing and publicity are different and highly specialized, and we used to respect this—but that is changing—with the blending of marketing and publicity.  We see marketing professionals writing press releases that do not produce results.  We see marketing talent too broadly. Organizations that want to reach a dependable, sophisticated audience need high level publicists in every organization or agencies that specialize and truly understand the news media.

It’s always been a challenge to break through the competition for ink, but using social media as a substitute for traditional media coverage is a mistake.  It is much better to engage in an integrated campaign with both marketing and publicity professionals working side by side.

Sarah Sherwood




















The Art of the Dinner Party

by Sarah Sherwood

Think of the beginning of your Twitter, Facebook and LinkedIn experience, building an audience until it takes off. That is the ancient art of the dinner party. 

They come to forget about the stock price, the mother in law, or the missing pearls. Some come nervous; some cannot wait to jump in and put their best foot forward. 

As with well-designed social media campaigns and sites, it needs to be a great place to go. You’re throwing a dinner party; fun and indulgence in the 1920’s will forever have its place. Making it perfect requires details just as important as the photos in Pintrest, or the recommendations on LinkedIn. 

A dinner party must be a place where people can come to forget about their troubles, and gather to celebrate life with friends, acquaintances, and people they would want to meet. It doesn’t have to break the bank—it has to distract in order to bring out what is lovely about life: good hearted people, lively music, delicious food and then things like color, a little nature a la flowers, and all in the appropriate spot and, just in time. 

To plan your party, like your web site, step back and ask yourself: when people walk in the door, for the first time, what do you want them to see? What do you want to communicate straight on? As they move about the evening, what do you want them to remember about their experience?

Good party (and on line) planning considers the visitor, and his likes, so that means you will consider whom she wants to sit next to—this matters tremendously. How can you encourage the best of conversations? Answer: with beautiful art, travel photographs and, in some cases, with children running around. People love to talk about other cultures and their kids. 

Put away your electronics, unless they are truly the next best helpful thing, and do not, and I mean this, carry your cell phone. If you are the lucky guest, you must make sure that any technology you carry is transported with class. If your boss calls, please politely step outside. Being a nerd can be very helpful, but not at a dinner party. I have a friend who is a genius Hollywood high tech executive, and he has the best way of showing off with music and technology. He enlists his baby grand and highlights it with some beautiful black box that carries the music throughout the house. It works.

I think about web sites with phony, flashy technology and shake my head.

Once they have arrived, take good care of your people. Refresh them with not just a drink; but with your prized smile. A happy host or hostess, not overdressed, but elegant and kind, steals the show. 

Now it is time for the toast. Make it about someone you love and you will shine. If you fumble, laugh at yourself and carry on. If announcing you are running for office, be human.

And then you know you’ve made it; you look around and even so and so is having a great time. Because, and this is the point, the conversation they longed for has taken place. 

Ah, community. Someone needs to tell Sartre that heaven is other people, too.

How Women in Business Are Moving Forward

by Sarah Sherwood

This is still so pertinent I want to republish this article from two years ago…

As seen in the Grassy Road Blog:

“Don’t be a woman in drag,” went the article. “Act like a lady,” was the advice. In my 20+ years as a publicist I have seen this kind of counsel hurt women both personally and professionally. The truth is that women have been transcending this kind of advice since we have worked outside the home, which is as long as men have been working, actually. We’re acting as if women just walked into the boardroom and they can’t figure it out, when working is what women have been doing for many, many years. It’s mildly annoying to be told how to be, how to act, or how to go through any “how-to-be” training program.

At American University, where I studied public communication, there were basically two different camps in communications theory, a.k.a. preparing clients for how to be, in public. One group believed that public communicators must tightly control the client and then manage closely, moving them with the script. People in politics tend to follow this formula.

The other group believed more in authenticity, arguing that you can damage their communications with too much control. This group of communicators give their clients a few perimeters based on their goals and work with the client’s own style to bring out what they want to say. This makes some communication professionals nervous. What it does is force them to sign good clients who have positive intentions.

I’ve been in the later camp since I left graduate school, but even more now. This is what we women need to do: lovingly, and without worry, self-police ourselves. Speak up, yes, and speak authentically. People can see right through the kind of personal positioning that Penny refers to in her post because the words you choose are insignificant compared to the tone you use, which come from your beliefs. When you come from what you believe you’re always more powerful. This is what I tell women.

Successful women have figured out that to solve problems, we need to first prioritize, hire what we need, work hard and be who we are. That’s it. These women are taking time out to raise their children, or looking for good quality childcare. They are having long talks with their husbands and their bosses. They are concerned about quality relationships in and out of the office. And they are making it work. They always have.

From my perspective, it is easy to see that people everywhere are oversold. They see through the B.S. and yearn for a quieter place. What do they want besides an efficient solution to their problem? They want honesty—basically a friend in business. How many companies have this kind of relationship with their public? I applaud those who do.

So please stop telling us how to behave. We moved on a long time ago, figuring out that it is much better and much easier just to be us.

Improving the Image of Physicians in the U.S.

by Sarah Sherwood

In Dr. Kaci Durbin’s excellent article today for entitled Doctors: You Have a PR Problem, she describes the response to the negative portrayal and assumptions of physicians as near silent amidst the firestorm of criticism. Indeed, the public perception of physicians has been on the decline, while they are being framed as greedy and limited in knowledge. As a communications professional who has worked with scientific organizations for more than 25 years, I can assure you that not enough has been done to correct this misperception—a larger communications campaign is needed to ensure the integrity of the physician reputation. The basic communications lesson is this: If you don’t continue to define yourselves in an effective way, you will be defined by someone else. And that someone else doesn’t understand medicine as you do. Here are my recommendations:

1.  First, Increase Your Understanding of the Communications Profession

“Next to doing the right thing, the most important thing is to let people know you are doing the right thing.” – John D. Rockefeller

What is PR, exactly? In the medical field, there is a lack of understanding of what good communications is all about: educating the public with facts and important points of view. Good PR professionals share the truth, connect scientists with the right reporters and utilize critical third parties to educate the public. Professionals with international agency experience, and/or agencies on the international level have the skills necessary to actually alleviate perception problems. They present the facts effectively not just to the traditional media, but also directly through integrated marketing and social media campaigns. Your job is to be available to speak out on behalf of the profession and your patients.

Action:  Hire International Agency Experience to Integrate Improved Skill into Your Campaigns

2.  Move Out of Your Comfort Zone: Speak Out

I speak about this regularly because it is so critical to public identity. Being defined by your audience is often not a good place to be, because there is a true lack of knowledge when one doesn’t go through medical school or have the experience with patients over the long haul. The public doesn’t benefit from this lack of knowledge about physicians, and what they actually do for patients and society. The images we hear about are reinforced by the physician scientist, who has been socialized by our culture and through medical school to speak conservatively. But studies show that physicians have a strong intuitive side and many are extroverts—and these are the professionals who would make effective spokespersons. However, I have worked with many introverts who are successful in educating the public in a substantive way. What matters is that you do speak out. Your concern about patients each and every day is equally critical to the message as showing how much knowledge one has.

Action:  Cultivate Excellent Spokespersons

3.  Coalesce To Build Strength in Your Public Communication

Keeping quiet has significant negative ramifications, but struggling through this negative perception individually is worse—not just on morale, but on the collective reputation. An effective public campaign includes a coalition that shows strength in numbers and in the extrinsic commitment to patient care. There are many great physician organizations who concentrate on their members, but not enough on reputation and public identity. The good news is it is easily remedied through effective public education campaigns.

Action:  Support each other publicly as well as internally, with a shared campaign

4.  Empower Female and Minority Scientists To Speak Out and Educate

The physician reputation doesn’t need to soften or be ultra-personalized—that is a mistake—instead, it needs to show effectiveness and inclusion. There are patients who need to hear from female or minority physicians. Particularly, the history of women in the profession, recent and even not so recent, is not always so helpful and can add to the negativity. But that is changing, and there are many male leaders in medicine who regularly empower their female colleagues. Moreover, the strength of each culture involving women and minorities can only add to the profession’s reputation. Show off the brilliant diversity in medicine and diminish the perception (and myth) that medicine is only for white men.

Action:  Increase the comfort with the profession through important groups

Thanks to Dr. Kaci Durbin and others, we are moving toward solving the identity problem in order to understand the necessities and complexities of the profession and transition from the problem she so aptly describes. Medicine needs to be understood. Medicine needs to be appreciated for all it provides, under sometimes difficult circumstances. Medicine needs a public information campaign.

Sarah Sherwood is a publicist who has been practicing since 1990. She can be reached at