Kim Vopni (00:02.01)
Hi, Dr. Chauberti, thank you so much for taking the time. I think this is one of the episodes I'm the most excited about. I put it out to my community in terms of what questions they wanted me to get covered, and I was flooded with responses. So you're a man that people are watching and very interested in terms of the work that you're doing, and I really, really am grateful for you sharing your time with me today, so thank you. I'm going to hand it over to you. If you can introduce yourself in terms
Abbas Shobeiri (00:09.848)
Oh.
Kim Vopni (00:33.031)
why so many people are paying attention to the work that you're doing, what you do for work, where you are in the world, and then I'm going to have some more specific questions for you. Yeah, it's a thank you so.
Abbas Shobeiri (00:42.64)
Yeah, it's thank you so much first of all for having me. It's such an honor to be able to really address the patients and their questions. I realize that they are not getting the answers they need. So it's very meaningful to me to be given this opportunity. I really don't know why everybody is paying attention to me. I think you need to answer that question. I think each person has a different reason.
Kim Vopni (00:47.15)
Thank you.
really address the patients and their questions. I realized that they are not getting the answers they need. So it's very meaningful to me to be given this opportunity. I really don't know why everybody is paying attention to me. I think you need to answer that question. I think each person has a different reason.
Abbas Shobeiri (01:15.263)
I'm very passionate about my patients and what they do. And I think a lot of times patients just talk to each other and they come to me for different reasons.
Kim Vopni (01:15.65)
very passionate about my patients and what they do. And I think a lot of times patients just talk to each other and they come to me for different reasons. So you are based in, you said Washington DC area, sort of Northern Virginia, is that correct? Correct, yes. Yeah. So I'm just gonna say that I'm very passionate about my patients and what they do. And I think a lot of times patients just talk to each other and they come to me for different reasons.
Abbas Shobeiri (01:35.0)
Correct. Yeah. So, and I think the next part of your question was to introduce myself and see who I am and what they do. Thank you. So the, uh, yeah, if you're familiar with Washington DC, it's really strange area with all these different states coming together. Very northern Virginia health system called Innova Health System that serves the northern Virginia. Um, so it's really Washington DC capital region. And then, um, what's, um,
Kim Vopni (01:39.59)
if I am not going to do it. Thank you. So if you're familiar with Washington, this is a really strange area with all these different states coming together. There in northern Virginia, a health system called Inowa Health System that serves the northern Virginia. So it's really Washington, NBC Capital Region. And then what's the?
Abbas Shobeiri (02:06.28)
I do, I am the head of the gynecology program for our health system. So any minimally invasive surgery, urogynecology, so on and so forth, that's what I do. In terms of my background, I have been a urogynecologist for a long, long, long time. It seemed like I was, feels like I was grandfathered into this. I was getting my training when there wasn't really much
Kim Vopni (02:06.57)
I do, I am the head of the gynecology program for our health system. So any minimally invasive surgery, gynecology, so on and so forth. What I do in terms of my background and being a gynecologist for a long, long. I do have a lot of other things to do. I do have a lot of other things to do. I do have a lot of other things to do. I do have a lot of other things to do. I do have a lot of other things to do.
Kim Vopni (02:27.451)
It seemed like it was grandfathered into it. I was getting my training when there was a really much of a Euroganicology track. And just as I was getting the training, they came with the making it official and making it of a specialty by the American board for BGY. But I was very passionate about the field mainly because, you know,
Abbas Shobeiri (02:35.38)
track and just as I was getting the training, they came with the making it official and making it a sub-specialty by the American border for BGYM. But I was very passionate about the field mainly because you know as a medical student this was in 1990s and I walked into an operating room. It didn't
Kim Vopni (02:55.85)
as a medical student, it was in 1990s when I walked into an operating room, it didn't seem like a single doctor actually owned the patient, you know, like a OBGYN would come in and say, hey, I'm going to do a strike, I mean, and that a urologist would walk in and say, hey, I'm going to be doing a sling procedure and like a colorectal surgeon would walk in. And I don't know, to me, as a lowly, as a doctor, I'm going to be doing a sling procedure and like a colorectal surgeon would walk in. And I don't know.
Abbas Shobeiri (03:05.16)
a single doctor actually owned the patient, you know, like a OBGYN would come in and say, hey, I'm going to do a straight to me and then a urologist would walk in and say, hey, I'm going to be doing a sling procedure and like a colorectal surgeon would walk in and I don't know, to me as a lowly, not very smart medical student, I thought it was like a zoo. I'm like, you know,
Kim Vopni (03:26.63)
not very smart, maybe because students, I thought it was like a zoo, I'm like, you know, I was thinking, you know, I joined, that began the area, we would really need three, four people to operate in this area, so. So, and that was a shortcoming that I think the American border, OVG went also, recognized that, you really need to have 10 people operating on one small area, you just needed to get one person trained too. Take care of all that area.
Abbas Shobeiri (03:35.16)
We really need three, four people to operate in the same area. And that was a shortcoming that I think the American border will be able to recognize that you really didn't need to have 10 people operating on one small area. You just needed to get one person trained to take care of all that area. And then the other thing that really blew my mind, I think, as a resident was, I think,
Kim Vopni (03:55.75)
other thing that really blew my mind, I think, as a resident was just, as a student, how much women were misunderstood. And as a resident, just blown away by me, how little was on about public floor. They even the basics that you needed to know
Abbas Shobeiri (04:05.36)
just as a student how much women were misunderstood and as a resident I was just blown away by how little was known about pelvic floor like they even the basics that you needed to know what a pelvic floor is people didn't know or appreciate. So and me while I was looking at doctors doing that.
Kim Vopni (04:25.79)
health, glories, people didn't know or appreciate. So, and meanwhile I was looking at doctors doing their surgery, and I was asking about these questions of why don't you please, what about this, you understand the basics, what are the muscles, what are the fracture, what are these things? And really there was a lot unknown, and me being a very curious person, first of all just really connecting with women all
Abbas Shobeiri (04:35.02)
their surgeries and I was asking all these questions, why don't you do this? What about this? You understand the basics, whether the muscles, whether the fascia, whether these things and really there was a lot unknown and me being a very curious person. First of all just really connecting with women all together and being able to converse with them, which was my natural area was great and so this is a population I cared about,
Kim Vopni (04:55.75)
able to converse with them, which was my natural area was great. So this is a population I cared about. But then really nothing was known about the basic pelvic floor that they needed to understand. So make the long story short, I decided to do a fellowship for the audience who may not know. What it means is that you finish your four years of medical school.
Abbas Shobeiri (05:05.32)
really nothing was known about the basic pelvic floor that they needed to understand. So make the long story short, I decided to do a fellowship. So for the audience who may not know what it means is that you finish your four years of medical school and then you do your internship and residency, which in my case was another five years of training in OPGYN and everything else. And then you do three years of training.
Kim Vopni (05:25.83)
internship and residency, which in my case was another five years of training in OPG YN and everything else. And then you do three years of fellowship training on top of that. So by the time I was done it was like 17 years of higher education. Wow. But just being a very curious person, we had to do a thesis research in my research
Abbas Shobeiri (05:35.5)
fellowship training on top of that. So by the time I was done, it was like 17 years of higher education. But, you know, just being a very curious person, we had to do a thesis research in my fellowship. And I really wanted to understand the basic
Kim Vopni (05:56.43)
fellowship and I really wanted to understand that they think an atom in off-telvic floor and things that were not described so my thesis project became so humongous that they actually didn't complete it for almost like three four years after I finished my fellowship and the reason it took so long was I just
Abbas Shobeiri (06:05.12)
me off pelvic floor and things that were not described. So my thesis project became so humongous that I actually didn't complete it for almost like three or four years after I finished my fellowship. And the reason it took so long was I just looked at the findings that I had and you know I was looking at all this and I was just trying to find out what's the basic
Kim Vopni (06:25.93)
at the findings that they had and you know I was looking at all these and I was just trying to find out what's the basic anatomy of pelvic floor where are the muscles what what inner weights and really nothing that they had found was described in books or written anyway and I was so looking at this and I'm saying gee I really think I may have done the dissection wrong maybe I you know maybe this
Abbas Shobeiri (06:35.04)
of pelvic floor where the muscles what what innervates it and really nothing that they had found was described in books or written anywhere and I was so I was looking at this and I'm saying gee I really think I may have done the dissections wrong maybe I you know I maybe this maybe that and then I read a paper from a German guy from like 180 years ago where he had described some of the same fibers that they had seen that nobody else had described so
Kim Vopni (06:55.79)
paper from a German guy from 180 years ago, where he had described some of the same fibers that they had seen that nobody had described. So generally, when you talk about pelvic floor, you're talking about the levator in the muscles, which generally, they're very misunderstood. People think of levator in their muscles as muscles that connect to a bone, and that's what they are. They're just very complex. And I was looking at the muscle fibers that had not been described
Abbas Shobeiri (07:05.76)
Generally, when you talk about pelvic floor, you're talking about the levator in the muscles, which generally they're very misunderstood. People think of levator in their muscles as muscles that connect to a bone, and that's what they are. They're just very complex, and I was looking at the muscle fibers that had not been described so far, but like puboidalis, pubopernialis, muscles that were, I was seeing in my field. So I did that.
Kim Vopni (07:26.13)
people in Alice, people in the Alice muscles that I was in my field. So I did that, I showed all the number of muscle fibers that existed in a woman's pelvic floor. And this was really important because to stimulate injury and create biomechanical models of injury
Abbas Shobeiri (07:35.08)
all the muscle, number of muscle fibers that existed in a woman's pelvic floor. And this was really important because to simulate injury and create bi-medical, bi-mechanical models of injury and try to reproduce it on a computer, you need to know exactly how many numbers of muscles you have, what their properties are. So those were the kind of things that we used to create
Kim Vopni (07:55.75)
to reproduce it on the computer, you need to know exactly how many numbers of muscles you have, what their properties are. So those were the kind of things that we used to create the models that you, if you see like animations of pelvic floor and childbirth, they have used basically a lot of the information that they created. And then also, we looked at the innervation of the pelvic floor that wasn't described up to that point. So I think
Abbas Shobeiri (08:05.0)
the models that you, if you see like animations of pelvic floor and childbirth, they have used basically a lot of the information that they created. And then also we looked at the innervation of the pelvic floor that wasn't described up to that point. So I think I published this and everybody got up and said, who cares? Why do you really need to know?
Kim Vopni (08:28.391)
I published the interview with the god up and said, who cares? Why do we really need to know this information? And we're just doing our therapy. It's really important for you to know the basics of what you're working on. You just can't be doing stuff. And I was like, OK, great. I spent six years doing this. I'm like, if Kim comes to me, I cannot, they say,
Abbas Shobeiri (08:34.98)
this information and we were just doing our surgeries. And I was like, it's really important for you to know the basics of what you're working on. Just, you know, you just can't be doing stuff. And then, and I was like, okay, great. I spent like six years doing this. How am I going to, how am I, you know, like if Kim comes to me, I cannot dissect her and look at her muscles and say, this is your pupil, perinealis muscle, and this is your elevator. And I muscle like, how can I, how can I see them? And they had,
Kim Vopni (08:55.77)
to cut their muscles and say, this is your people, perinealis muscle, and this is your elevator, and the muscle, like how can I see them? And they had, MRI was available back then, but very much it was. The pictures were still fuzzy, and it was in the realm of research at that point. And still it's expensive part to do. We don't routinely use MRI, but they had come up with,
Abbas Shobeiri (09:04.96)
You know, MRI was available back then, but very much it was. The pictures were still fuzzy and it was in the realm of research at that point. And still it's expensive, hard to do. You know, we don't routinely use MRI, but they had come up with what's called BK ultrasound machines. And this was a, I think a Danish company that created Sonar for World War Two.
Kim Vopni (09:26.33)
what's called BK ultrasound machines. And this was, I think, a Danish company that created sonar for World War II. And they have created these really cool ultrasound machines, and they have created these specialized probes for colorectal surgeons. And I saw these and they said, wait a minute, if I put this inside the vagina, would I be able to see all the things that they need to see? So,
Abbas Shobeiri (09:35.8)
They had created these really cool ultrasound machines, and they had created these specialized probes for colorectal surgeons. And I saw this, and I said, wait a minute. If I put this inside the vagina, would I be able to see all the things that they need to see? So I literally suffered the company to loan me one of these machines. And I took to the cadaver lab, and I don't want to gross your audience.
Kim Vopni (09:56.43)
I literally suffered the company to loaning me one of these machines and I took to the cadaver lab and I don't want to close their audience but then I asked the professors, I said there's not a cadaver, I ultrasounded a lot of them and I correlated them, I told me I picked cadaver with what the ultrasound was showing, that has not become the standard looking public floor anatomy.
Abbas Shobeiri (10:05.06)
and anatomy professors. I dissected a lot of cadavers and I ultrasounded a lot of them and I correlated that anatomy of the cadaver with what the ultrasound was showing that has now become the standard for looking at pelvic floor anatomy. And just to put it in perspective for you, when we talk about ultrasounds, there are two types of ultrasounds. And this is something we get a lot
Kim Vopni (10:26.05)
And just to put it in perspective for you, when we talk about ultrasounds, there are two types of ultrasounds. And this is something we get a lot, like people would reach out to me through Instagram or Facebook and from Europe and say, somebody did this ultrasound on me. And they do like a perineal ultrasound. And this is not the same as what we do. We do an endobasional ultrasound. And the reason this is important is you're literally getting a very small probe.
Abbas Shobeiri (10:35.54)
people would reach out to me through Instagram or Facebook and from Europe and say, somebody did this ultrasound on me and they do like a perineal ultrasound and this is not the same as what we do, we do an endovaginal ultrasound and the reason this is important is you're literally getting a very small probe that is not uncomfortable at all inside the vagina but it's very strong it's like 16 mega
Kim Vopni (10:55.75)
that is not uncomfortable at all inside the vagina, but it's very strong. It's like 16 megahertz of energy. And the muscles are literally millimeters away from it. So when you do the alters on that way, it's just like looking at the histological slides of the muscle. So nothing really escapes you. And it's hard to show superiority of one technology over other, but I always like MRI
Abbas Shobeiri (11:05.74)
millimeters away from it. So when you do the ultrasound that way, it's just like looking at the histological slides of the muscle. So nothing really escapes you. It's hard to show superiority of one technology over other, but I always put MRI and R-alternation side-to-side and R-alternation always have so much detail in them.
Kim Vopni (11:30.092)
are all first on side to side and are all first on all these have so much detail. Yeah. So, so, um, you know, I published that, uh, presented that and again, people got off and said, who cares why are you? I'm like, come on, you really need to know this. Why do you think, why do you think there's so much like to me, this is just it first of all, it's mind boggling that there, there are
Abbas Shobeiri (11:35.32)
presented that and again people got up and said who cares you know why are you showing us this stuff. But like common you really need to know this stuff.
Kim Vopni (11:56.07)
that nobody is standing up and celebrating and sending this out to the masses. Now of course I'm biased, I work in this field, but why do you think that is? I think you just need to look at what people do.
Abbas Shobeiri (12:06.56)
I think you just need to look at what people do. I have always been a little different. I always ask why. And then I really never, I don't think I actually did things the way that my mentors told me to do it. I always say, OK, I really think this is a better way of doing it.
Kim Vopni (12:17.391)
different and I hope it's just one.
I really never...
I don't think I actually did things the way that my mentors told me to do it. I always say, OK, I really think this is a better way of doing it. And I think what probably gave me the leg up was that I just really understood, I've done, I don't know, probably 500 to that very high section of so much studies. So I really understand the pelvic floor anatomy. It's just like being a, I don't know,
Abbas Shobeiri (12:36.46)
that probably gave me the leg up was that they just really understood, have done, I don't know, probably 500 cadaverate dissections and have done so much studies, you know. So I really understand the pelvic floor anatomy. It's just like being a, I don't know, engineer and going and looking at Golden Gate bridge and say, yeah, these are, these are the other components.
Kim Vopni (12:57.41)
engineer going and looking at Golden Gate Bridge and say these are the components and you know your pelvic floor is really built like a bridge with all the suspension cables and so on and so forth. I think other people they just want to do their surgeries you know but I'm really interested in understanding the hottest bridge boards you know right like if
Abbas Shobeiri (13:06.5)
builds like a bridge with all the suspension cables and so on and so forth. I think other people, they just want to do their surgeries. But I'm really interested in understanding how this bridge works. Like if a part of it has collapsed, it's not just enough that you go and you put a plank over it and just go to the other side. You need to understand why it has
Kim Vopni (13:27.69)
If a part of it has collapsed, it's not just enough to go and you put a plank over it and just go to the other side. You need to understand why it has collapsed, what were the forces, and rather than putting a plank over it, go and actually repair the suspension cables that have snapped and caused that area to collapse. Or if the foundation was an earthquake under the foundation of the bridge, that's where you need to go and work on.
Abbas Shobeiri (13:36.6)
collapse, what were the forces, and rather than putting a plank over it, go and actually repair the suspension cables that are snapped and cause the laryal to collapse, you know, or if the foundation was an earthquake under the foundation of the bridge, that's where you need to go and work on, rather than just keep trying to fix the bridge. And that's really what you see a lot of times, where people say, well, you know, public floor surgeries have a lot of failure, like, well,
Kim Vopni (13:56.51)
And that's really what you see a lot of times. Where people say, well, pelvic floor surgeries have a lot of failure. Well, it depends on really whether you actually be carrying, do you understand what you're repairing, or are you putting stuff to stuff and wondering why it's failed. Right. Right. So that's where we are. And so in terms of what I said, there's a lot of people watching you. In the pelvic health realm, there's realm. There's a.
Abbas Shobeiri (14:06.66)
you actually repairing, do you understand what you're repairing or are you just going, are you putting like stuff to stuff and wondering why it failed. So that's where we are.
Kim Vopni (14:27.871)
a birth injury called levator evulsion, levator anti-evulsion. And this is something that, statistically at least that I have seen, it's around 30% of vaginal births and there is some resolution for some. I don't know if you have any different statistics on that, but this is a very specific injury that not very many surgeons have the knowledge of how to repair it.
Abbas Shobeiri (14:33.46)
Thank you. Thank you.
Kim Vopni (14:56.59)
And I know that there are some that maybe are not repairable, so we're going to go into more about that. But first, can you, you've talked about the anatomy and the importance of identifying the anatomy. If you can talk a little bit about what, what are the muscles of the pelvic floor, and then specific to the levator ani or levator ani, however you would like to pronounce it, what, what are the muscles involved? Yeah. So, Kim, if you don't mind, I'm going to roll back
Abbas Shobeiri (15:05.96)
Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.
Abbas Shobeiri (15:21.46)
Yeah, so Kim, if you don't mind, I'm going to roll back a little and just give you an analogy that somebody gave me one time and that really made a lot of sense to me. It was, you know, the current state of science is that you're standing there. Bodies are getting washed down the river and you're just going down there and pulling them out of the river and you are resuscitating them and but then somebody needs to come and think where are these bodies coming from.
Kim Vopni (15:31.45)
It was, you know, the current state of science is that you're standing there, and bodies are getting washed down the river, and they're just going down there and pulling them out of the river, and you are resuscitating them. And, but then somebody needs to come and think, where are these bodies coming from? So, that's an analogy for pelvic organ prolapse, urinary incontinence, pelvic floor disorders. It's true that you have a problem.
Abbas Shobeiri (15:51.72)
So that's an analogy for pelvic organ prolapse, urinary incontinence, pelvic floor disorders. It's true that you have a problem now where we are standing by the river. But really where did this start? So in terms of pelvic floor injury and levitary anion injury, that's really where the problem starts. So just the analogy I use is that
Kim Vopni (16:01.39)
now where we are standing by the river, but really where did this start? Right. So in terms of pelvic floor injury and the ventricular a9 injury, that's really where the problem starts. So just the analogy I use is that you have connective tissue, you have muscles, you have things just like a bridge that are holding you together. And then if you.
Abbas Shobeiri (16:21.54)
you know, you have connective tissue, you have muscles, you have things that just like a bridge that are holding you together and then if you snap a few off the cable, the bridge would still stand on but it would be much weaker and then over the years just cannot sustain the forces and it's going to start causing prolapse in continents and so on and so forth. So
Kim Vopni (16:31.57)
snap a few off the cable, the bridge would still stand on, but it would be much weaker. And then over the years, just cannot sustain the forces. And then it's going to start causing prolapse, incontinence, so on and so forth. So a lot of people basically ask the question, like, why do we even care about these muscles? You know, we just do prolapse surgery. Why should we?
Abbas Shobeiri (16:51.36)
people basically ask the question, like, why do we even care about these muscles? You know, we just do prolapse surgery. Why should we go back upstream and look at these muscles at all? You know, we are down here 15 years, 18 years later, and we are seeing patients with prolapse and we are doing surgery on them now. So really changing that mindset that these muscles are important at all is the key, right?
Kim Vopni (17:01.35)
go back upstream and look at these musculos at all. You know, we are down here 15 years, 18 years later. And.
Abbas Shobeiri (17:21.38)
the, when we go upstream, where we go, where the injury occurs, right? You just need to remember, as a girl who got married, who has dreams, who really doesn't know much about pelvic floor, and who just wants to have a family, you know, what's on your mind about childbirth is very different.
experience you have now. And you would say, gee, I wish somebody told me this stuff before. Before I went through this. And the problem we have is that the way that the society views childbirth, as I'm going to go there, there are going to be waterfalls and rainbows, and it's going to be great. But really, not understanding that even though the percentages is really
occur, what are these problems and how can we address them. So going back to the question you asked, we really don't use the term avulsion as much, again because if you're using a technology that is not as accurate or maybe as sensitive, maybe if you're using a perineal ultrasound, they would tell you avulsion or avulsion. It means that the muscle snapped from the bone or the muscle didn't snap from the bones, right?
The reality is that these muscles are very complex. Imagine like the bowl that you use in your kitchen and just you put dough all over it. That's what these muscles are. And then you're going to stick three holes in them for the urethra and the vagina and the anus to go through them. The muscles are very complex in their structure. True at one point they're attaching to one part of pubic bone, but the large percent of it.
98% of it is attaching to the sidewalls. So when we use the term avulsion, we are using the term that orthopedics use for your shoulder muscles, and say the muscle tore from the bone. So it evolved. So the same term was used in the pelvic floor when the muscles are just so much more complex. And then when we do endovaginal ultrasound,
Abbas Shobeiri (19:51.62)
we can see these muscles in all their details, in all their subdivisions. And the way we looked at them is really tactical, where we are just like having bright eyes and looking at the, again, Golden Gate Bridge and say, you know, this cable has a snap, I need to change it. This support structure has a snap, I need to change it. So it's very tactical, it's not avulsion, no avulsion. But going back to the question you asked, the true avulsion in our mind
when the muscles puboctalis, pubococcigis, ilioococcigis come undone from everything. So if I see a patient where I see those three muscles basically are totally undone from the whole. So imagine again just if you have that ball with the dough in it, imagine the whole dough has pulled this from the side and it's sagging on one side.
Kim Vopni (20:32.871)
So if I see a patient and where I see them.
Abbas Shobeiri (20:51.56)
or if you have bilateral injuries, like all of the dough has come undone on both sides of the the wall. So the the true avulsion incidence is probably around 13 percent. You know, the truth is that we did a study where we actually ultrasounded patients, and we didn't look at avulsions and we just looked at all sorts of injury in the pelvic floor. And
baby, the muscles just stretch, you know, and they have to spread as long as they can to let the baby to go through. And then what happens is that the muscles are literally stretching and shredding. They create small hematomas. They create small blood clots or sometimes gigantic blood clots in there. But when we did this somewhere about like 45% of patients had large blood clots. And when we look at, if we look at patients with the smaller blood clots, it tends to be like around like 70%.
And I don't call these injuries, I would call these physiologic changes, because the muscles have to stretch to let the baby through, but when we alter us on the same patients a year down the road, really most of all those hematomas and blood clots have gone away. So what the body does is that it goes and the muscle has shredded in the middle, it comes and sort of repairs it. And then maybe scars it.
Kim Vopni (22:11.25)
So what the body does is that it goes and...
Abbas Shobeiri (22:21.4)
the muscle won't be as strong and that's where even women who don't have avulsion or injury they just don't feel like their muscles as strong anymore. That's because the over stretching of the muscles but when the muscles, when the injury comes from their point of connection, so like ilucoxigial connection to obturator internus muscle or pubic oxygis connection to obturator
Abbas Shobeiri (22:51.4)
were all attached to both pubic bone and obturatorial externus. So if all of those connections come undone, then you know, then you have a valzian, that's about 13%. And that's what we call catastrophic injury. And if you're one of the people who have actually had this happen to them, it was catastrophic, you know, and the you probably don't have to wait
Kim Vopni (23:02.75)
And that's what we call catastrophic injury. Yeah. Yeah. And if you are one of them.
Abbas Shobeiri (23:21.9)
you know, like I talked about, you know, then you basically would may have prolapse immediately, may have rexosilimediately, you may have uterus fallout immediately. One problem that we have is that just going back to the birth process is that, remember, nobody can even can tell you how the birth process can be or how you feel. It's a different thing for each person.
in all the swelling and soreness that you're experiencing, you really can differentiate if you had muscle injury or you did not. You literally would just lie there and say, this is normal and nobody else is complaining about this. So why should I be a wimp and complain that I'm sore? And then you know you, the problem with that is that even in patients
Kim Vopni (24:02.91)
Yeah, that's such a good point. That's such a good point.
Abbas Shobeiri (24:21.36)
have muscle injury right after childbirth, when you do vaginal examination on them, everything just looks out of distortion. So when a physician looks at a vagina after delivery, they would say, well, this is normal. This is just the way it's supposed to look. And they really don't have any way of saying if there is muscle injury or not.
Kim Vopni (24:49.55)
So generally, you are feeling like that. And two weeks, three weeks has gone by, and you're still feeling that discomfort. So I'm going to go back to the question. What is the difference between the two? What is the difference between the two? What is the difference between the two? What is the difference between the two? What is the difference between the two? What is the difference between the two? What is the difference between the two?
Abbas Shobeiri (24:51.48)
you're feeling like that and you know I don't know two weeks three weeks has gone by and you're still feeling that discomfort something is wrong you need to see a specialist that has really expertise in what we do and there are few and far in between so the you really don't want to just see a urogyne ecologist you want to see a urogyne ecologist who has some degree of imaging
expertise, either they know how to do at least maybe MRI or maybe do transperinal ultrasound and the ultimate in my mind obviously is if they can do what we do which is an individual ultrasound. So.
Kim Vopni (25:35.35)
So it's honestly shocking to me listening to you talking that. So I've already asked you the question of the people who are looking at what you're proposing, you're presenting with your research and your thesis statement. And no one's really giving much interest. And then when you talk about the statistics, you just threw out and also just the, even if somebody again, doesn't walk away with a catastrophic injury, there's disruption to the tissues and to the function in every single person giving birth vaginally.
Why is there not more attention given to prehab and rehab? In my opinion, pelvic floor physical therapy is something that I think should be playing a vital role in all births to help rectify or at least identify some of these things before. Because as you say, people come out and they of course feel different, but they have nothing to compare it to. So they don't necessarily know if this is catastrophic or just how it is.
I just honestly am floored. But so... So...
Abbas Shobeiri (26:38.36)
Thank you. Thank you.
Kim Vopni (26:41.15)
You being one of the few people who has the imaging, but also who is doing repairs for these injuries. So why is it again that there aren't more people wanting to get trained by you or the people who trained you potentially to learn these practices, knowing that these are such common injuries? So I think I'm going to just.
Abbas Shobeiri (27:05.04)
Yeah, so I think I'm going to just roll back a few sentences if you don't mind Kim, just, you know, I think having patients pre-habilitate or see the physical therapist or whatever we are, proposing to them without having an accurate diagnosis, is just going to frustrate the heck out of them, right?
The physical therapist, I love them, we have too many of them, too many pelvic floor therapists that in our health system, I'm totally with you, but they have learned to just like come back to me and say, what was the accurate diagnosis of this patient? What did the ultrasound show? Because I mean they always are like texting me, messaging me, like what did your ultrasound show and what is that you're recommending? Because if this person had muscle injury, I don't know.
don't want to do the things that they was going to tell them, right? And then what that's, you know, what you, I mean, I really don't get floored or shocked. I just see a problem and I say, how can I solve this, you know? And I empathize with the patients and they try to find solutions for them. There is a great interest in this area, but you just need to see the enormity of the problem, right?
If, you know, one thing that I'm really passionate about in this population and that just gets my heart bleeding is just a lot of times the ones that they see also have PTSD. Like they have postpartum PTSD and especially with them, like when I do ultrasound for them, say they have been going around for like three years trying to figure out what's wrong with them. They have seen physical therapies.
that person and the psychiatrist is saying you just need to take more medication to get this PTSD under control but they really never had an accurate diagnosis because they keep going around and telling people there's something really awfully wrong here that wasn't wrong before but once we alter us on them I wish I had a study like to get their facial features because I mean sometimes
Abbas Shobeiri (29:34.96)
crying because they're like, oh my gosh, there is actually something wrong with me like I told all these people. And sometimes there's this relief of saying, I can't deal with this, I have a problem, now I know what it is. So accurate diagnosis is the key. Now when we talk about the enormity of the problem, if we say, when we look at three to four percent incidents of PTSD in postpartum population, you're talking about like 120,000.
patients that basically go undiagnosed without an accurate diagnosis of PTSD and they never treat it. They live their lives like that. If you go with 12% or 13% gyscovulgen, then you're talking about 400,000 patients that go undiagnosed in the United States alone with levator and ayahulgen.
have problems immediately or they will have problems down the road or sometimes you just say this is how it's supposed to be being a woman, childbirth, this is what it is. But the problem is enormous and I am training physicians all the time. Any conference that there is, Shover is giving an ultrasound workshop, we have international research folks coming here.
to learn what we do, they go back to their own countries to learn how to do it. And then it's just that it's a core competency that physicians don't have. The OBGYNs are trained to do ultrasound to look at your uterus and ovaries, but it's very different with doing pelvic floor ultrasound for looking at pelvic floor muscles. So we...
Well, we have, I think, I think we are the largest fellowship training program in the country and we have like six fellows. But literally every fellow that works with me, you know, literally they have called me by the scene of we have to rearrange our wiring when we go back to other services because now we are used to looking at patients' insights, seeing what, you know, making the diagnosis that way.
Abbas Shobeiri (32:05.04)
into the real world where things are a little different and we just have to switch back. So you know, we are training people but really just changing the whole structure takes a long time. But that's why I accept your invitation to come and talk on these kinds of programs because patient education is huge. For women to know that there are solutions.
Abbas Shobeiri (32:34.96)
Solutions and you know just don't take the answer that is given to them You know you just have to be a smart consumer
Kim Vopni (32:38.99)
Maybe it's just up to the consumer. Yeah, well, that's good to hear. I appreciate you saying that, and I appreciate all the work that you're doing to train other people because it is definitely needed. So we've talked about the group of muscles, the levator and what makes up that muscle, the group muscles. I love the dough analogy in the bowl, and you mentioned how it can be one side or potentially both sides. So regardless of whether it's one or both,
how, what is the repair of, and I don't know what the other term is that you use, that's not a Volsion, but right now I'm calling it that because that's what we know. But how do you repair whether it's a unilateral or bilateral lateral Evolgen? So, so.
Abbas Shobeiri (33:13.16)
Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.
Abbas Shobeiri (33:20.16)
Thank you. Thank you.
Abbas Shobeiri (33:27.46)
So, so the, so basically, you know, when you use the word avulgen, you're basically saying that there are two types of injuries, either avulgen or avulgen. When you, when you look at all these different muscles and you become tactical in each one of them that may, may get injured, there are 36 different varieties of injuries that a woman can have.
When we look at that, we basically would see a patient and we would say, okay, you have like defecatory dysfunction, pooping problem. It's something that people are saying that it has to do with your GI tract. But what happened was that you tore up your iliocoxy gel muscles and your rectum rather than being a straight pipe. It's a wide pipe where the stool just connects.
and you can't poop. You know, so it's very tactical. Like, so you need to know the anatomy. You know, it's like, if this muscle, where does this muscle normally sit? You know, I'm going to dig down and I'm going to find it and I'm going to pull it up and I'm going to reattach it to where it's supposed to be. Right? So that's how the surgery is done. So they,
Kim Vopni (34:54.195)
So they...
Abbas Shobeiri (34:57.48)
two issues, like two core competencies that we need to teach physicians to be able to do this surgery. The number one core competency is teaching them how to do ultrasounds, you know, or imaging of some sort if you don't have ultrasound available to you. And these technologies are expensive. Sometimes the hospitals just don't buy it for you, at least be able to do MRI or something, you know. But if you do, if you are able to get the
ultrasound that's that's a core it's not the machine that you need it's the knowledge that you need to have so really literally for my fellows it takes them a year to to learn how to interpret images and how to dissect the images so basically what we do with ultrasound we are dissecting the patient
front of them. The ultrasound literally takes about five minutes to do and as they are sitting there we go and look at the data and we say look this is where your problem is and it's actually very educational for them. So I really feel like you know first of all ultrasound we need more people as mentors that need to know how to do ultrasound but these are older folks so it's hard to teach them stuff right and then it needs a year they need to
a year off to learn something and they're in their 50s or whatever. So we need to get it in the training programs to be part of our regular urogynecology fellowship programs. The other thing that we probably should do is just have straight ultrasound fellowship programs where we say, you know, great, you did your urogynecology fellowship in such and such place and they didn't have the ultrasound expertise.
but here we are offering you a one-year program to do this. Again, then it's a manpower issue and we do have we do offer something like that where people are coming and getting those training. So once they have that core competency of doing the ultrasound, the next core competency they need to have is surgery, right? Now we are asking them to do very delicate surgeries where you're
Abbas Shobeiri (37:27.32)
delicate muscle to different structures. So people ask me like how do you do it? I'm like well gee you know it's hard to explain you just need to understand the anatomy of the Goldegate Bridge and know which wire needs to go to which area and connect them to that. So if you really don't understand the anatomy then it's really tough to teach you. So there are some good surgeons there and I'm pleased to say that like at least our fellows when they are graduating our
I think they have level of confidence to go and do it, but then the question is that wherever they are going, do they have the resources to do the ultrasound to keep up? And then really for me, my practice is literally dedicated to postpartum patients, where I'm just like, okay, she has postpartum, I would see her, she doesn't have postpartum problems, I won't see her. I mean, but then it's difficult to say who is postpartum or not.
Kim Vopni (38:09.75)
Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.
Abbas Shobeiri (38:27.32)
delivered 15 years ago but I attribute my problem to that childbirth, then I need to see them. So it's...
Kim Vopni (38:36.15)
Yeah, so that was a question I had actually is, you know, because a lot of people will say once you've given birth, once postpartum, you're basically postpartum for the rest of your life. So does it matter in terms of the success of the surgeries? Does it matter how soon or like if somebody waits that 15 year postpartum person who finally now has some answers because they've found you, is it too late or would it affect the outcome?
Abbas Shobeiri (39:02.56)
Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.
Kim Vopni (39:06.431)
Would it be better if that person had been seen earlier and had the surgery done within a year or two years?
Abbas Shobeiri (39:15.381)
So this is just like paddling across Potomac and trying to figure out what's the best way to get to the other side and that's what I've been doing. Literally trying to answer these questions. I mean, first of all, remember it took me literally, I don't know, 20, 30 years of trying different things and I have described many different ways of repairing these muscle injuries. You know.
at another level the past probably five years and what we have learned is that so for example if you are the patient and you deliver it and you come and see me and you say I delivered about two months ago something is awfully wrong. We have a the protocol we have developed is that you would get full assessment physical examination, questionnaires, etc and you get ultrasound at the
Abbas Shobeiri (40:12.96)
delivering a baby just looks not great, you know, no matter who it is. It's just like there are a lot of blood clots, et cetera. And I say, okay, we have a baseline of how things are. And we are going to the protocol calls for ultrasound in the union six months and then six months afterwards. Right? But the point is that we need to ultrasound you a year after and see how much healing has occurred. And that's one thing that we are researching
ourselves because you know why is that again maybe in the curious person why is that two women who look alike, act alike, had exact, seemingly exact same delivery and may even seemingly the same injury healed differently right why is that when I see them a year after you know patient A has persistent injury and patient B has healed. Now I believe that if they have true
which is tearing off pubaric thalus, pubococcus, geosilucoccus, all together, nothing magical will happen. The muscles are not going to magically crawl up the sidewall of the pelvic floor and attach themselves where they're supposed to be. But then I think with that one year, we are giving them enough time for the dust to settle for us to see what has remained and what we can do. But when, so once we have established, and we say that this is the problem you have,
Then we really need to see where in the reproductive life cycle we are catching the patient, right? Is this your third baby or is this your first baby? Was your dream to have two babies or five babies? What's going on? I generally basically recommend please get done with your childbearing. If they have had true injury, I would recommend for them to have a C-section for the next baby.
point you know something they tell me like but it's injured is it okay? I'm like no it can get injured more don't don't you don't injure it more you know it makes my job harder so get a C-section you know and then when you are done with your childbearing then we assess you at that point and give you surgical repair options right and then
Kim Vopni (42:35.99)
Does it, does it, um, sorry to interrupt you. I just have a question on that. If, if somebody, so somebody has, let's say they have a, a, a unilateral or bilateral, uh, evolution. Does that change the capacity of the uterus at all during the pregnancy? Does it make things more challenging for them to even carry a pregnancy?
Abbas Shobeiri (42:57.24)
That's a really good question. A lot of patients just ask that. You know, I'm looking at the screen and I'm like, oh my gosh, you know, you tore up your muscles and she's thinking, can I get pregnant again? I'm like, yeah, yeah, you can get pregnant. So I know it doesn't affect their ability to get pregnant and carry a pregnancy. They probably would feel more pressure and discomfort and they may even have prolapse during early stages of pregnancy.
as the hormones kick in and make things less, you know, so the, and remember when these injuries occur to the muscle, if you're exerting so much force to your pelvic floor that the muscles rip, more likely than not there's some connective tissue injury as well. So when we say for example if I have a patient with, that I identify that, for example, she has a right-sided
some pivocax, a GSC injury. And I go repair that at the same time I'm going to repair anything else that I see at the same time. You know that I can identify as weakness to try to give them the best chances of healing. So and sometimes again if they do have prolapse and so on and so forth and really there is big structural damage to both connective tissue and the muscles. The muscles give
Kim Vopni (44:12.89)
Yeah. Sometimes.
Abbas Shobeiri (44:26.82)
so the other 50% we need to go and correct everything.
Kim Vopni (44:31.43)
So then coming back to the, you know, I know it's intricate and I appreciate how long it's taken you to become trained in this. The question though that so many people have is how do you actually take those muscles and reattach them? Do you reattach them to bone? Do you suspend them from other areas? Is it with mesh or is it with native tissue?
Abbas Shobeiri (44:59.48)
No. So basically we use sutures, and we use sutures, pull the muscle up and connect it to wherever they connected to before. And you literally never need to connect it to bone, okay? Because, and that's really one thing sometimes I get people send me questions like, do you screw it to the bone? Do you suture it to the bone?
what are you doing?" I'm like, no, no, no. Where the muscle was attached to the bone, there was a ligament there. And so you basically can get the end of the muscle that is scarred now and you suture it to that ligament. But remember again, that part that people concentrate on is literally, I don't know, 5% of the whole area of connection. The rest of your connections are like if you're talking about iliocoxygies. I'm going to throw medical lingo out there,
so people start like, you know, breaking down Google engine. You know, so yeah, like Iliococcus Gs is its point of attachment to the sidewall is Arches tendenius. Arches tendenius fascia pelvis that is attaching itself to the obturatory internus fascia, right? So when we get in there to repair these things, you know, sometimes Arches tendenius, which is a ligament
It can be stuck to the sidewall, can be floating in the air, like a piece of wire, can be attached to the muscle that is retracted next to the rectum. And then, so you just need to literally, like closing a zipper, you need to put suture, suture, stitches, stitches, stitches, just put it back where it was at one point, and then you, you know, you just keep on going. You know.
Kim Vopni (46:56.451)
Got it.
Abbas Shobeiri (47:00.42)
and ultrasound say these are the defects and that's really the other gratifying thing that they must say is like there there was a there's a still a debate that really all these things that you see on ultrasound like are they real you know or do they exist you know we literally have not had anyone we did surgery on where we went in there and ultrasound said that the show the defects and then we didn't see them in the real patient so that has been very
Kim Vopni (47:30.23)
That's amazing. So the integrity of the person's tissue is really important. So this is coming back to the one question I asked with regards to how long after. So some people could be, say, 15 years after this injury has happened. Potentially, this person is now approaching menopause, and there's a hormonal change that is starting to happen to the tissue as well. Can that influence the success or the
capacity for those sutures to hold.
Abbas Shobeiri (48:04.5)
Basically, longer it takes after childbirth, when I go in there, I can tell you like 10 years later when I have attempted to go repair them, I'm basically looking at fatty tissue and really no usable muscle tissue to use because the muscle as it's detached, it's literally atrophies. We still go and try to look for them.
Abbas Shobeiri (48:33.88)
enough data to say but all I have learned and all I know is that earlier I can go and put the muscles back together better success I have of finding them.
Kim Vopni (48:46.53)
Yeah, that makes sense. And this is not necessarily a question particular to a vulgar, but general pelvic surgeries. Would you say the same would be true that so somebody, you know, many people are told wait as long as you possibly can, because there's a chance of recurrence. So you might as well delay your first one knowing that that's going to happen. But there's the other argument, which is sort of what you were just saying, where if we wait too long, the, the. There's more sagging.
Abbas Shobeiri (49:00.06)
Thank you.
Kim Vopni (49:16.45)
drag on the muscles, there's more atrophy to the muscles. So potentially the person is faced with an even bigger surgery afterwards. So kind of sooner is better. Is that what is that accurate to say?
Abbas Shobeiri (49:29.42)
Yeah, I mean drawing from other disciplines where you know, that's what we know we know that if a muscle injured sooner you Go and put it backwards supposed to be more functional. It is now having said that in real life as a pelvic floor surgeon, I'm very conservative, right if a patient comes to me I Don't know in their 40s 50s and they have prolapse I basically do all the conservative things that I need to do to
to try to give them the quality of life they want, because that's what it is about. It's really not about correcting prolapse, probably, but it's just giving them quality of life. And if it has already been so long after the initial injury and the muscle injury, I won't be able to correct the muscles at that point. And we see this as a matter of fact, like when the patients are early after delivering a baby,
and the muscles are disconnected, you can actually see the muscles right sitting there and then there is a black area between where they are and where they were supposed to be. And that can be measured versus when I look at somebody who is many years after delivering their baby and we do ultrasound, literally all we would see is just the vagina and the rectum and urethra and etc. and the muscles have turned into fat. So when the on ultrasound fat looks black.
dark and there's no muscle striation there. So with these people we know already where their muscles and what the status is, so we don't even go after them.
Kim Vopni (51:10.17)
So that would be somebody who, like in terms of who would be a good or not such a good candidate, somebody who has lost some of the muscle striation, it's maybe been longer, a longer period of time since the injury happened, they may not have a successful outcome and you wouldn't necessarily go forward, is that correct?
Abbas Shobeiri (51:21.926)
Yeah.
Abbas Shobeiri (51:27.74)
I basically rely on their ultrasound because if the ultrasound shows me muscle and it shows me it's there then I know I have something to go after but if it's just not there then I know that we don't want to do unnecessary surgery for patients either. So.
Kim Vopni (51:45.27)
Are there any of the muscles within the pelvic floor that cannot be repaired? So are there any, you know, injury presentations that are beyond repair? So, yeah, I think that's a good point. I think that's a good point. I think that's a good point. I think that's a good point. I think that's a good point. I think that's a good point. I think that's a good point. I think that's a good point. I think that's a good point. I think that's a good point. I think that's a good point. I think that's a good point.
Abbas Shobeiri (52:00.18)
I mean we have seen them on and we have, it's really like being a carpenter and being knowing the anatomy of the room that you're working in so you just go in there and put things back together. The you know, iliocoxiges, people coxiges, people are exhaled, they can all be repaired. They, not muscles but there are some connective tissue that are harder
Abbas Shobeiri (52:29.02)
etc. they're harder to repair but and also like puboid and alice injury that's you know a lot of times we see patients who have like anal pushing of the anus like it's the anus doesn't have the support because the muscles just have been disconnected and those really there's no good way of repairing puboid and alice muscles and then that would be more of like a colorectal thing where they then they go get mesh push it out on the rectum and pull it up that way.
Kim Vopni (52:32.15)
Thank you. Thank you.
Kim Vopni (53:00.033)
Do you ever use? Sorry, go ahead.
Abbas Shobeiri (53:00.081)
But the, yeah, but pubopyrinialis, puborextalis, pubococcidius, iluococcidius, we fix. I think puboanalysis is the only one that probably is a colorectal issue.
Kim Vopni (53:13.45)
Do you ever use mesh or is it just sutures?
Abbas Shobeiri (53:18.781)
We don't use mesh for muscle repair. We use mesh for strengthening the uterus sacral ligaments. So basically if somebody has what we call AP-COLP prolapse, means that if this is the vagina at the very top where the uterus is telescoping through and you need to support that ligament, then yeah, we basically open up the uterus sacral ligament, put mesh in it and then bring it wherever we need to.
And that's called sacrocopal pexy for the people who are not familiar with it. So we do that for apical support, but really there is no advantage to using mesh for muscle repair because you just need to get the muscle and put it back where it needs to go.
Kim Vopni (54:05.391)
And are the surgeries performed through the vagina?
Abbas Shobeiri (54:10.16)
It's a combination. I generally do them robotically and vaginally.
Kim Vopni (54:17.81)
So there was a study that came out, I think it was just sort of a review of a number of different, you may have seen this, but talking about the use of robotics and how it can help with some of the more intricate aspects. So when you say some robotically and some vaginally, where does the robot go? Like where does that incision happen?
Abbas Shobeiri (54:42.021)
Yeah, yeah, no, it's when we say some robotically, it's in the same patient. So for example, if I see a patient with pelvic floor injury after childbirth, the chances are that almost 100% that we do both, both robotic surgery and vaginal surgery on them, because of the question you asked, like, where are these muscles going to some of them are easier to reach vaginally, some of them are easiest to reach a robotically. So when you do robotic surgery.
Robotic and laparoscopic surgery, just for the audience, they're literally the same thing. Okay? Laparoscopic surgery, you use little things that look like straws and put it through the belly and then you use that to put the instruments through. And that way the patient doesn't have a big incision to do what you need to do. But it's really cumbersome for the surgeon. You know, by the end of the surgery,
a backache and etc. So robotic, what happens is that you put the same sort of straw instruments in the belly but then you bring the robot over the patient and then robot will be following your commands so you would be sitting on the side, you're sitting comfortably so you're not getting a backache and then you're doing your surgeries with the robot. So robot doesn't make you a better surgeon, you know, you have to be a good surgeon to use the robot to its
One advantage that robot has for us is the spaces that we go into are very small. You know, I mean, you're literally talking about, you know, for example, you can see the alters on the alters under the iliocoxiduse muscle, for example, is torn from the sidewall, but when you measure it, it's like it's torn about a centimeter. So a centimeter is a tiny amount, and then I need to go find it and bring it up and suture it back up.
the same thing with the other muscles. So the degree of separation of the muscle is not really great, but when you're talking about pelvic floor hiatus or elevator hiatus, literally it's a hiatus about that big, where the bone is here and the muscles are going around, when you like have a one centimeter separation, your small muscle hiatus becomes really much bigger than it's supposed to be.
Abbas Shobeiri (57:09.84)
of it is such that you just need to have really fine instrument handling to get into the space that you need to get to and you cannot do that with laparoscopy. And then the spaces that you want to think about, just imagine you're sitting, if you touch right where your pubic bone is and where the clitoris is, we are behind the bone and that's how low
VR in terms of trying to get your muscles. But the instruments are going through your belly button and et cetera to get that far down. So that's the other thing is that with laparoscopy, sometimes our instruments are not long enough to get way down there. So just, yeah. So then you do ilocoxygies, pubococygies, like pubo-rectalus, repair, all of that can be done robotically. And then.
Kim Vopni (57:49.17)
Let's see how their thing is a bit like.
Abbas Shobeiri (58:09.76)
then we do also fascial repair and then we go vaginally and then repair the other things that need to be repaired as well.
Kim Vopni (58:17.756)
How is the fascia repaired?
Abbas Shobeiri (58:22.06)
That's a big question. I think my question for you would be which fascia, right? So there are many different ways of basically preparing the fascia with the muscle injury. So I'm just going to use this paper that I have here and I'm going to use it for analogies.
that sort of goes under your bladder and your bladder is sitting on top. The muscles are on the side, right? So when the muscle tears up, what happens to the bladder is that it doesn't have, the tissue doesn't have anywhere to attach itself to, so the bladder falls. So you, you get a cystic seal, right? So if you go see a normal person to, who looks inside your vagina, they're like, hey, you have a cystic seal.
to go through the vagina and repair it, they really wouldn't know that you have muscle injury. So they go and get this tissue and like sort of bunch it up and stitch it up and that actually makes your cystocil worse. So then, so that's why it's actually important to do ultrasound to see what's the patient's underlying problem, right? So for us, say now the patient has a cystocil and their muscles were here, but now they're down there, right? It's not enough for me to bring the muscle up here and attach it where it was.
Now I have the tissue sort of still floating down there I have to bring the tissue and attach it to the muscle as well Right, so you you end up not only doing muscle repair and also doing maybe a paravaginal repair Robotically, but it's really important to remember that like paravaginal repair is not muscle repair You know and that's sometimes what I get questions on like people reach out to me and say is this what you're doing? I'm like No we're getting the muscles and we are putting
Kim Vopni (01:00:13.15)
You know, I guess I'm...
Abbas Shobeiri (01:00:21.66)
where they belong. And then, so that's like one type of fascial repair. On the other hand, if your muscles are intact and the fascia is attached and maybe when you deliver the baby, the fascia tore right in the middle and you go see your general objvian or your gynecologist, whoever is doing your muscle, fascial repairs, yeah, when they open the tissue vaginally and do just what we call anterior repair, it's gonna take care of your problem. So again, you
Kim Vopni (01:00:27.05)
the other hand, you feel muscles.
Abbas Shobeiri (01:00:51.7)
high level of curiosity, clinical acumen of saying this is a muscle problem, this is a tissue problem, and then basically the connective tissues that you need to know just to educate people, you have a tissue that separates your vagina from your bladder that's called pibocervical fascia, and then you have again another tissue the same way that separates the vagina from the rectum, and that's called rectovaginal septum.
Right? And then I don't have two hands, but just if I'm going to use the same paper, so if, let's see, can you see it? So if this is the tissue that goes under the bladder, that tissue that goes under the rectum, you know, your utero-sacral ligaments are coming from the corner and holding this up on both sides. So they are supporting the utero-sacral ligaments are pulling your pubocervical fascia and rectovaginal fascia up. Right? So, that
There are many different ways of repairing the fascia because again if the uterus sacral ligament has come undone, for me just going and putting a suture right, stitch right next to that corner is not going to be enough contact point. So in those cases I need to, I'm not using muscle, I'm not using mesh for muscle repair. I'm going to, just like an orthopedist, I'm going to reinforce your uterus sacral ligament with mesh.
and then I come and grab the people's cervical fascia, grab the recto vaginal fascia and pull the whole thing up. So your muscles are repaired, you know, and your fascia has been strengthened.
Kim Vopni (01:02:34.35)
Got it. So you're, there just, I think you sort of answered the question there that I wanted to ask is that fascia can be restored either with the help of mesh into ligaments or with sutures. Correct. So you can use sutures into the fascia as well.
Abbas Shobeiri (01:02:50.088)
Yeah.
Yeah, you can use, the fascia is harder to see than muscles. So we muscle, we can see 100% certainty that, you know, you have muscle problems. If you're a normal patient who has never delivered a baby, I can easily see your pubocervical fascia and rectovaginal fascia. But once the fascia gets injured for one reason or the other, it's harder to see on the ultrasound. So you have to sort of use your clinical examination,
examination and ultrasound knowledge together to deduct what needs to be done. So what we'd like to do is really correct all the defects that we see while the patient is under anesthesia so they won't have to come back and say, hey, I have this problem. Now having said that, sometimes we may do surgery on patients and they may come a year later, six months later, six years later.
say something is pushing out that I didn't feel before, I can tell you generally like in our surgery, the patients never fail where we did surgery. Where they may fail is just again going back to the Golden Gate Bridge, is that we went and repaired all the floor and we repaired all those cables that had a snapped, but now they have snapped some cables that were not snapped before,
part of the floor is giving up where I didn't need to repair because it looked normal to us at that point. But because of the aging, because of the tissue changing, now something else has come undone. So it's not the failure of surgery, it's really failure of the body.
Kim Vopni (01:04:41.67)
got it. So would you, would you are you a supporter of pelvic floor physical therapy after surgery and on an ongoing basis to help prevent or mitigate the chances of that happening?
Abbas Shobeiri (01:04:56.4)
Oh, absolutely. So I'm gonna use another analogy for you, Kim, and that's my analogies. Hopefully, I'm not gonna just drive you crazy, but just like this person giving me too much analogy. So let it, yeah, good. So let's do this. I'm going to create a pelvic floor for you, right? So say, can you see this? So this paper that I just turned into a cone, thin coffee that's your connective tissue, right? So it's connected.
Kim Vopni (01:05:07.271)
I love the analogies, they're helpful.
Abbas Shobeiri (01:05:26.64)
tissue I'm too close so yeah that's actually better it was too close. So this is this is your connective tissue your vagina your rectum your bladder everything are going through there right and then if I I'm going to get my eye drops and just make it that's your uterus and we're just gonna drop it in there right so pelvic floor exercises are these muscles that are holding the opening of the cone closed right if the fascia is weak you know obviously if you
those muscles, it's going to some degree help you, but it's really not going to correct that problem, but it's going to help the strength of your muscles. Now the problem we talked about was that what if you don't have muscles, right? Now if I send you to physical therapy, it's going to really frustrate you and frustrate your physical therapies because you're not making any progress. So sending the right person to physical therapy is a great idea and as a matter
the status of all our patients, all of our patients are going to PT after four. But basically, again, just going to that, just see what happens. When I let my hand go, the eye drop literally just falls out, right? Because the muscles have weakened and then the connective tissue literally unravels and things come. So physical therapy is very, very important to strengthen the muscles that you have. And again, just not to diminish physical therapy.
if you don't have intact pelvic floor muscles, because there's a lot, the physical therapists manage you in a holistic manner, right? So just when you look at your your pelvic floor, like a Roman bridge, and the Roman arch, when the integrity of the Roman arch is compromised, your posture is not the same anymore. The way that you handle your body is not the same.
is not the same. So a physical therapy may not be able to strengthen your pelvic floor, but they would do other things that would compensate. So the way that you would, for example, breathe would take the pressure off your pelvic floor. So just again, we have 20-some pelvic floor therapies, and we are used. They're too busy. We need more if you need some. Send them to us. We'll hire them.
Kim Vopni (01:07:56.73)
Yeah, the world needs more pelvic floor physical therapist, I agree. So how, I have a couple of questions. How long do the surgeries, and obviously it's going to be dependent on what you find in that person, but how long would it typically take to repair, say a unilateral evolution? And then I'm curious about the recovery, recovery time. And also if there are limitations that people have, it's very common for people after, say, a prolapse repair.
be given lifting restrictions, sometimes given lifting restrictions for the rest of their lives. So I'm curious about are there any lifelong restrictions that these people will have after they've had a surgery with you?
Abbas Shobeiri (01:08:39.64)
Yeah, that's such a really great question in terms of restrictions. The answer to that is that really nobody knows what's the right thing to do afterwards. One thing that I do know and makes a lot of sense is that whatever you do, don't do squatting exercises. Squatting is like if you go to third world countries, that's a position for pinging and pooping
it relaxes your pelvic floor so you can do those actions or if you know spreading the legs just really relaxes those muscles so don't do squatting exercises I'm sort of answering your question backwards like the but don't do that in terms of heavy weight lifting again it's not really as important how much you're lifting it's how you are lifting it right again if you squat and you
10 pounds, the pressure that goes to your pelvic floor is tremendous versus if you get on one knee and lift 100 pounds, none of that goes to your pelvic floor. So again, this is one area that a good physical therapist can really guide you on. And that's what we tell our patients, go and work with the PT and they're going to help you with handling and lifting and so on and so forth. Going back to other questions. Really, how long do these things take?
take, you know, with the area is highly vascular, you know, as a matter of fact, like when we look at the ultrasound, there's like blood vessels all over the place. So when I do surgery, I'm not looking at the clock. I'm just thinking of my patient safety. I'm going slowly and surely and just doing my things, you know.
and we never do muscle repair alone. It could take, depending on what we do, it could take anywhere from four to six hours. So not really easy things to do and their lengthy things to do. And they're very meticulous and they're very, you know, I don't know, if any of you do quill thing, you just have to have a beautiful outcome. You need to be very methodical.
Abbas Shobeiri (01:11:08.76)
they call them what you are doing. I do quit.
Kim Vopni (01:11:10.37)
Yeah, I I marvel honestly at the work that you do and and the use of robotics with it. I just I'm it's fascinating So thank you for being curious and doing all the things that you do Um, and I want just before we we start to wrap up. I I'm also now curious with regards to success rates so the the How many of these have you performed what's the You know, if you think back to the first person you did
any sort of long-term data, how long are these surgeries lasting? Do people need to have multiple surgeries over a lifetime? You may not have the data on that yet, but what sort of figures are we looking at?
Abbas Shobeiri (01:11:50.76)
Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.
Abbas Shobeiri (01:11:54.2)
So yeah, you're not looking at a great number of figures because again, just a lot of these patients, as I told you, you know, we identify injury, but they won't do surgery on you. Basically, I say, go do your reproductive life cycle. I'm here for you. And then we'll go. So patients are coming back and coming back. But we just looked at it and we haven't published it yet, or hopefully,
to do the full analysis and submit it for the American Urgine Society meeting this year. I was going to send it to Ayuga. I got COVID and etc. And they just couldn't do anything. But I think we have done somewhere about maybe 30 of these repairs. And then right now I think about 18 or 19 of them are immediate depost-partum. The
the success rate, I can tell you that like patient-oriented outcomes are really good where patients come and say you know I don't have that pressure that I had anymore and things have you know they I feel good about it right and then what we are doing we are alter-sounding them afterwards to see really how things look like and what we could do better or differently and what
what are the reasons somebody may feel better than the other person. So again, just looking at this as carpentry, like I'm putting point A to B and just connecting things. Anatomical success rate is 100%, right? So because we are just putting things where they belong to begin with. We have about maybe three year follow up outcome where patients are doing well.
had a recurrence. There was one patient who was from other states who told me she had like pressure and she felt like she had recurrence and they said, let's come back in for us to see you and I haven't seen her back so I don't know. And I think there was like one patient that they tried to approach it vaginally first and it didn't work. It was before I was good at it robotically and then we went to the other.
Abbas Shobeiri (01:14:24.2)
did it robotically and that worked out well. So for most part here it's a lot of work both for me and the patients so I really don't have hardcore data on terms of like what they can do or what they can do but I basically beg them not to overdo it you know even they're feeling great because they wake up and they just have a few poke holes and they're belly and like oh this is great I can go home you know and I'm like gonna leave my kids and etc. I'm like please you
You know, we just did a great amount of surgery in your belly. Don't overdo it. Don't stress my suture lines because even if you cut your hand, you know, a small cut on the hand and you look at it microscopically, it takes about a year for it to heal. You know, so just because you're feeling good doesn't mean things are done and finished in there. About somewhere about like 60% of your healing happens the first three months, somewhere about 80% the first six months.
doesn't complete for the whole year. So the body, once we do surgery, what body knows what to do is it goes and dumps collagen in there, trying to minimize damage. And then after it thinks it has done a good job, it goes and reorganizes it and tries to make it as normal as possible. So we use permanent sutures. We use like Gore-Tex sutures to do the things we need to do for this to stay. And
but then again I just tell the patients to be careful, work with their physical therapies, work on their handling of their body because again we don't have 10-year outcome data or you know so on and so forth and most patients that we have seen, not most I think, all of them have don't have pure muscle injury, they have muscle and fascial injury. So we are correcting everything and then going back to the success rate again remember
They're like when we look at the types of injuries We looked at like 200 patients that we had done ultrasound postpartum and where there were 36 different variations of injury so it's really hard to say which group you are in and Really, I literally need to have I don't know like 30 people in each 36 group to say that this is your long-term success rate and I don't think I can
Abbas Shobeiri (01:16:55.845)
lifetime on this, all of your listeners get an appointment tomorrow and try to ask them.
Kim Vopni (01:17:01.151)
Yeah, that would take a little bit of time. And then, from a recovery perspective, I love what you said with regards to it. It's not this like six weeks and you're ready to go back to normal like so many people are told whether it's postpartum or postop. And there needs to be sort of a gradual progression back. It's taking things easy. And you know, what's the best way to do it?
Abbas Shobeiri (01:17:15.16)
Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.
Kim Vopni (01:17:29.25)
When you were saying how when muscles have come away and there's been some atrophy, how long does it take for them to regain some of their function? Are the muscles able to regain function once they are reattached?
Abbas Shobeiri (01:17:44.34)
Yeah, so that's actually interesting because like when we look at the ultrasound, because as I said, the amount of separation is not that great. So when we go and suture it, because it's a surgical area, it looks like there is a still dark area and we just see a suture there, right? But functionally, it seemed like the patients are doing a lot better in terms of being able to squeeze, do key goals, and knowing that they actually have muscles there, that, you know, one of my, somebody reached out to me and said, my pelvic
floor is dead, like, you know, like that dead feeling sort of goes away. Another thing that I wanted to say that I just want to stress whether the patient has levator injury or not, it's whenever I'm doing surgery on a patient, their psychological state is really important to me. I'm a big believer that you heal
and really the all of the healing is not up to me. I'm going to go there and put the stitches there but this issue is really important for our patients with levator injury because as I said I'm yet to see a patient with levator injury who didn't have PTSD and that's actually like a passion of mine and I just you know I saw one yesterday who who was telling me about her
symptoms, and she even used the word trauma from delivery and etc. and she's seeing a therapist and so on and so forth. And I said, has your therapist ever told you that you have PTSD? And she said, no. Nobody has told me. I said, could you please go tell them that you need to see a PTSD specialist because you really need, this is what's going on. But getting past that PTSD to me is really important. And the way that patients...
describe it a lot of times is heartbreaking but I don't know how much you know about me but I actually like I'm a professional painter and the only thing that actually paint is my patients feelings so sometimes I go home and somebody tells me something that gets stuck in my mind and I start painting that emotion but just to advocate for the patients as well but getting them to the baseline of being positivity and really just knowing from coming from a
Abbas Shobeiri (01:20:14.68)
of knowing that they can heal themselves, I think is really important to me. I've had patients that, not postpartum patients, but people who are just like literally very negative. And literally no matter what we do, it's just like a downhill and we can't stop it. So be positive whatever you do and we can help you. I know sometimes it seems hopeless, especially with our patients who have seen
Kim Vopni (01:20:37.553)
Yeah, I love that.
Abbas Shobeiri (01:20:44.721)
and many therapists and so on and so forth, but there is hope out there.
Kim Vopni (01:20:52.05)
I love that. That's a great way to end. I couldn't agree more. Your time is precious, and I really, really am so grateful that you have shared all of your knowledge with us. And all of the ways that people can reach out to you will be listed below. I'm also really, I love watching you on Instagram. There's not very many people like you who are sharing things on a social media platform, and I just, I really am so grateful. And I'd love for you to share some of your paintings. I think
such a special way as you say to kind of process the feelings because you take on a lot of the weight that these people are experiencing as well, right? When they're telling you their stories and so you have an amazing outlet for you to get that off your plate. Yeah.
Abbas Shobeiri (01:21:38.041)
You know, I wasn't much of an Instagram person, being an older person, but I realized my patients were younger. And a lot of times when they came to me and I told them things, again with the PTSD, it's like, didn't absorb. And sometimes it would take three months to absorb. So I'm like, okay, you're young, you're on Instagram. If you guys go to doctor.shoberry.
Abbas Shobeiri (01:22:06.6)
doctor Instagram account. So I basically, anytime I had a conversation with the patient, I went and recorded that for them and I said, please go look at this video tonight and then the day after and just let me know if you have any questions. So the videos were made really for my own patients but other people are finding their way to that. So if you go to doctor, I'll say she'll vary. And then in terms of painting, I've always been a painter, right? And then I
So just looking at my patients, I was thinking, how is the way that I can advocate for them? Because the way to injury and trauma is such an underestimated problem. It's under-recognized problem. And really, how can we let the society know that this problem exists? That literally 13% of our women are feeling this fear.
and it's not acknowledged and they have PTSD and it's not acknowledged so how can we so I if you if the audience wants to look at it is if you go to showberry art on instagram and also showberryart.com showberryart.com doesn't really have much of the painting is more of a platform but the instagram there are some of the paintings I do have a if people are interested
Abbas Shobeiri (01:23:36.84)
of these paintings. And just to, for you to know what I did, I was looking at the patients and I'm trying to understand PTSD, which is something I wasn't really trained in. But as the years went by and people started telling me stories or the way they felt, I started like grouping them together over like a 20-year period. And I said, huh, this is what Kim says is like what
said and what like there is a group that are exactly feeling the same and these groups feels this this way and I just couldn't make the connection but then they then I realized that they were all sort of on a spectrum of PTSD recovery and what it was like was that they it's the it's a there's a cycle of mourning
described, some people described as seven stages, some described as five or nine stages, but the patients were mourning the loss of the functionalities that they had at one point. Now they didn't have it anymore, whether it's sex, you know, pain, you know, pressure, whatever the human being they were before, this happened to them. Now they were not the same human. So they were literally mourning the loss of that functionality.
Abbas Shobeiri (01:25:06.72)
of recovery, but if their physical injury, to me it seemed like if their physical injury is not diagnosed, they literally get stuck in one space. So if you feel such a tremendous anger and you know something is wrong with you and your life is a mess, but your physical injury is not diagnosed, you're gonna be stuck in that anger stage or in the sadness.
stage or whatever that is. So what I did, I basically got those statements and matched them with stages and sub-stages of loss that the patients were experiencing, loss and recovery. The painting series is like 32 paintings that basically tell a story. So to do this, I actually had to find an appropriate venue because no gallery is a long gallery. That's
Kim Vopni (01:25:58.33)
do this I actually have amazing
Abbas Shobeiri (01:26:06.42)
You can, so where we have it is called Dupont Underground, which is an old abandoned railroad station in the middle of Washington DC. And we have basically all of the paintings are going to go from a stage one to stage seven with different sub stages, so there are like 32 different stories that
Kim Vopni (01:26:27.91)
Wow, when is this? When is it gonna be?
Abbas Shobeiri (01:26:30.78)
This is going to be the whole month of May. So it's, and the way DuPont Underground runs, it's Friday, Saturday, Sundays, because Washington DC has so many museums. So, you know, the galleries and exhibitions have difficulty competing with them, and everything is free by the way. So, they exhibit the spaces open from like 11 to five every day, like the, and it's the whole month of May, the first weekend, there is,
Friday there's a reception and there's a talk, there's an artist talk that I'll be giving. And then I think the very last weekend, there's a book that goes along with it, like there's an art book. It's pretty much like a coffee table book. It's very expensive, don't buy it. It's like, I'm just producing it. Just producing it. My wife is like, you're spending so much money on this book. I'm like, it's an art book.
Kim Vopni (01:27:23.739)
Thank you.
Abbas Shobeiri (01:27:30.76)
expect to do. But for those of you who have extra cash to buy the book, I will be signing it up for them at the end of the exhibition. So it's going to be... But again, the point of it is really just advocacy for the problem so people know that this exists. So even if you cannot come to see it in person, these are just really amazing paintings. I've
Kim Vopni (01:27:38.85)
That's amazing. That's amazing.
Abbas Shobeiri (01:28:01.08)
all my life, but these are just, each of them tell a story, even if you can't come and see them, go and subscribe to like Shoberia Art and share once once I put the story out there, share it with your friends, because this is just a way, it's not just about Shoberia's art, it's about the fact that people are suffering and they have injuries and like Kim said, we just need so much more stress on
education and awareness and really literally all hands on deck to make sure that this just doesn't stay normal. Thank you.
Kim Vopni (01:28:41.41)
Yeah, yeah, I can't wait. I didn't know this about you and I am so excited. I absolutely love art. I do my own art sort of just a little bit on the side and I hope one day to have a gallery, but it actually will be nothing pelvic health related, I don't think, but I'm really excited to see that and I hope that people will come and see you. So huge, huge thank you to you for your time, for the work that you do, for the people that you are helping. You really, truly are
Kim Vopni (01:29:12.271)
for so long. And also the work you're doing to train others so that we can get this around the world because there's injuries all over. So thank you so, so much. Thank you. Thank you.
Abbas Shobeiri (01:29:23.84)
and Kim I want to thank you for what you do. I know there are a lot of things that you could do besides being a vagina coach, but this is your passion. But, and this is really very, very important. I mean, you know, just the fact that you are using the word vagina publicly, you know, right on down there or down below or something. It's just another body part that people have and it's very important body part that has
important functions that we don't talk about. You know, peeing, pooping, sex, orgasm, these are just functions that we take for granted and when they don't work anymore, you're just miserable. So just having a vagina coach in this world is amazing. Thank you.
Kim Vopni (01:30:12.993)
I appreciate that. Thank you so much. Yeah, thank you. Super, super grateful for this conversation.
Abbas Shobeiri (01:30:20.3)
Thank you.
