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Dr. Salvatore Cuccomarino

A passion born from childhood

I have always been curious and fascinated by everything around me. I was lucky enough to be born in a small town on the shores of the Ionian Sea, in Calabria. In the 1970s and 1980s, in places like that, children could grow up free, not only from the fears that cage kids in big cities at home today, but also - and perhaps above all - from the fake needs that are imposed on us by society today. Back then, being was more important than having.

My curiosity was very much alive, like that of all children; and nature, the very landscape around me, continually gave me cues to ignite it further. Why do the waves move? Why is the sea one color in the morning, another in the evening, yet another when it rains? How is it that beautiful flowers grow from a dry tree in spring?

I thought life was a wonderful play in which all the parts, all the actors, depended on each other, were all indispensable and in harmony, each with its own role interconnected with those of others, and that I was one of those actors, like a small atom that becomes part of a much larger molecule, but without which the molecule would be completely different.

Arrived at theuniversity, I became passionate about the disciplines that most represented this principle of uniqueness and indispensability in complexity: biochemistry, physics, anatomy, physiology, etc. However, when it came time to face the reality of the hospital, I began to realize that in the patients I saw admitted there was something profoundly disharmonious: not so much and not only the disease itself, but also the way of dealing with it.

I had decided early on to be a surgeon, precisely because the surgeon sees disease with his own eyes and puts his hands, as well as his intelligence, at the service of patient care; but I was troubled by the invasiveness of surgery even in dealing with "minor" problems, I was troubled by the pain of the patient and the unwillingness of my mentors at the time, in the late 1980s, to care about it.

Those were the years when the first news came from France about a'team of surgeons from Lyon, led by Philippe Mouret, which had succeeded in performing a cholecystectomy, that is, surgery to remove the gallbladder, by simply drilling four small holes in the patient's abdomen; this technique was called laparoscopy, and had been developed due to the great technological advances of those years.

In our hospitals, however, to remove the gallbladder, incisions of about 30 cm were made, which caused patients intense postoperative pain and forced them into bed for a week. Laparoscopically operated patients, on the other hand, would go home a couple of days after surgery. What an extraordinary difference: surgery could thus be "gentle", pain-free, respectful of the integrity of the patient's body and spirit.

After graduating with honors, I landed in Bologna to specialize in general surgery.

Upon entering the second school of specialization in general surgery, I was assigned as a tutor an extraordinary man, a brilliant surgeon who would deeply mark my professional history: the Professor Giovanni Ussia, from Calabria like me. Professor Ussia had studied in the United States and France and was one of the very few Italian surgeons at the time to master the minimally invasive laparoscopic techniques. With him I began my journey of learning minimally invasive abdominal surgery, including laparoscopic repair of inguinal hernias. This procedure, I confess, puzzled me at first.

In fact, "traditional" inguinal hernioplasty involves making a relatively small inguinal incision, and allows the hernia to be repaired under local anesthesia, with a simple technique and with discharge the same day of surgery. In contrast, although laparoscopic hernioplasty access is much less invasive (2 incisions of 10 mm and 1 of 5 mm), the technique is much more difficult and anesthesia is general, so the patient is discharged the day after surgery. When I used to expose my doubts to Prof. Ussia, he laughed and said, "You are young Salvatore, you don't have experience yet, but you will soon understand that less is more". Less is more: I heard him say it hundreds of times: less is more. Of course he was right: the less you surgically assault the patient's body, the more the benefits to him: less pain, less bleeding, less convalescence, faster recovery, faster return to his daily activities, to his life. We could say that laparoscopic surgery "gives life" to the patient.

In cWALL SURGERY - so in surgery for inguinal and abdominal hernias, laparoceles, and diastasis of the rectus - this is even more true; for example, chronic inguinal pain and skin sensation changes are about half as much after laparoscopic repair of inguinal hernia as after open repair, and the likelihood of recurrence is reduced by 30-50%.

In the diastasis, when comparing REPA with abdominoplasty, postoperative pain is greatly reduced, recurrences from 40% in abdominoplasty drop to about 3% in REPA, the risk of skin and belly button necrosis is reduced from about 25 to 0%. Less invasiveness, more benefits for the patient. Always.

In the time since then, I have made it a point to offer my patients the "plus" of the least invasiveness, in all possible interventions.

Professional development

My business actually started in 2008, with my decision to leave Italy for Spain. I had already been employed at the hospital for 7 years with a permanent contract, but I could not tolerate the organization of work, the pyramidal system that still plagues Italian public health care, because of which it is very difficult, for a doctor and a surgeon especially, to evolve professionally.

Especially, until 4-5 years ago, abdominal wall surgery was considered in Italy a "minor" surgery, more annoying than useful: this is despite the fact that it accounts for about 30% of all surgery performed in a hospital each year, and despite the fact that some of its surgical techniques, especially the minimally invasive ones, are of very high complexity.

In Spain I found a work environment completely opposite to the Italian reality: wide freedom and autonomy of the physician, meritocracy, very wide space for minimally invasive surgery: an ideal terrain to cultivate my aspirations and ambitions.

Returned to Italy in 2012, I tried to transfer the experience accumulated in Spain into my daily clinical practice. I opened my first freelance outpatient clinic, which due to scarcity of resources was for a couple of years located inside the hospital. I began to apply the minimally invasive techniques learned in Spain, in the fields of proctology, hernia and laparocele surgery, and abdominal surgery.

Since colon and stomach surgery was at that time monopolized by the chief surgeon of the time, I decided to invest in a niche that was still free, the wall surgery precisely, and to super-specialize in minimally invasive techniques.

I continued to frequent assiduously the Iberian and Latin American surgical environment and learning from my foreign friends and colleagues as much as I could.

In particular, I learned about the "existence" of the diastasis of the rectus as a pathological entity (in Italy it has long been a "forgotten" condition, considered only on the aesthetic side, without anyone ever bothering to investigate its pathological implications) and of a new technique for its repair, the REPA, developed by Derlin Juarez Muas, a young Argentine surgeon I knew.

I tried to understand what exactly diastasis consisted of; and when I learned that it affects 33% of women after childbirth, a HUGE audience of patients who were "quartered" by plastic surgeons every year with abdominoplasty, with really poor functional results, I knew that was the space I could and should occupy.

So I asked Derlin to teach me his technique step by step-it was early 2017. I began to explore the Italian environment, and found that in our country, on the one hand, the vast majority of surgeons underestimated or ignored completely the existence of diastasis of the rectus; while on the other hand, communities of patients with the condition were beginning to form and were very active on social media, spreading news - sometimes very wrong - about the condition.

I then decided to start interacting with these communities, telling them that it was not necessary to undergo highly invasive surgery to resolve the diastasis - that, in short, again less is more - and that the use of the network, which is "mandatory" in REPA, would greatly reduced recurrences. Thus the first patients began to arrive at the office.

My work today

On August 3, 2017 I performed, for the first time in Europe, the REPA. Since then, as I refined my technique and introduced some variations that simplified the procedure, I have done REPAs more than 350. I am the surgeon who has the largest case history of REPA currently in the world.

Abdominoplasty continues to have its indications, in patients with fatty aprons/excess skin: but in all other cases it is foolish to propose to a patient such an invasive and with so many postoperative complications to correct a diastasis of the rectus.

Today rectus diastasis has also entered, as a topic, the Italian congresses of scientific societies dealing with wall surgery and minimally invasive surgery; just as the idea of the importance of the postoperative physical therapy in patients undergoing surgery for diastasis of the rectus and other major abdominal wall defects.

I had also "stolen" this idea from Derlin; and I was the first to introduce it in Italy and to develop, together with my physiotherapist, a postoperative functional recovery protocol, based on hypopressive gymnastics (an advanced form of physiotherapy, in 2017 practically unknown in Italy but which has since become very popular), a protocol that was the first of its kind and which is now used worldwide.

After graduating magna cum laude in Medicine and specializing in General Surgery with highest honors from the University of Bologna Alma Mater Studiorum (during which he went to the Federal Hospital of Salzburg, Austria, for a year to perfect laparoscopic and minimally invasive surgery techniques), Dr. Salvatore Cuccomarino in 2001 won, first in the rankings, the competition for medical director of General Surgery in the current ASL TO4.
At the beginning of 2008, Dr. Salvatore Cuccomarino moved to Spain, to San Sebastian, where he worked, until the beginning of 2012, in the most important coloproctology center in the Basque Country (the Centro Guipuzcoano de Coloproctologia), established in one of the most important Clinics in the whole Kingdom ( Policlinica Gipuzkoa). Here, in addition to his full-time work in coloproctology, Dr. Salvatore Cuccomarino has further refined his techniques in advanced laparoscopic surgery, endovascular phlebology, and bariatric and metabolic surgery, performing, in four years, more than 1,500 major surgeries and several thousand minor surgeries, including instrumental outpatient treatment of hemorrhoids, which allows painless treatment of hemorrhoid pathology without the need for surgery, along with intensive basic and clinical research.
Dr. Salvatore Cuccomarino is an international instructor of open and laparoscopic abdominal wall surgery, a title awarded in 2013 by the University of Panama for his intensive teaching and operating activities in Latin America.
Dr. Salvatore Cuccomarino: surgical and scientific experience
He has performed as first operator-team leader more than 5,000 major surgeries, his main fields of interest being REPA - minimally invasive surgery of rectus diastasis - minimally invasive surgery of the colon, rectum, and anal region, hernia and laparocele surgery, morbid obesity surgery, phlebology with endovascular LASER methods, and laparoscopic surgery of the stomach and gastro-oesophageal junction. 
Dr. Salvatore Cuccomarino is a member of many medical-scientific societies, including SIC (Italian Society of Surgery), ACOI (Association of Italian Hospital Surgeons), ESCP (European Society of Coloproctology), SoHAH (Sociedad Hispano-Americana de Hernia), ESSR (European Society for Surgical Research), ISHAWS (Italian Society of Hernia and Abdominal Wall Surgery).

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