What’s new in surgery ?

American College of SurgeonsA short note about “what’s new in surgery” for those of you who did not attend the American College of Surgeons meeting (ACS meeting). (Basically there is nothing “new” and all that is “new” has been published before).

I hope that other members could and would add to the following:

Hernia

Bendavid from the Shouldice clinic claimed that their (Shouldice) repair, which in fact is a modification of the classic Bassini is optimal in the vast majority of cases, reserving mesh repair for the recurrent hernias or when the tissues are inadequate.

Amid from Lichtenstein institute supported “their” routine non-tension mesh repair. The open preperitoneal and laparoscopical approaches were discussed as well.

Bendavid advocates a routine excision of the cremasteric muscle -thinning the cord, while Amid proposes that the resection of the cremaster is contra-indicated. The latter advocates identification of “all nerves” while the former says it is of no importance.

All agree that cutting the nerves is not a significant problem but leaving a strangulated or crushed nerve behind is the problem. All agree that ligation and excision of the non-direct sac are not indicated; invagination of the sac plus narrowing of the ring are adequate.

“Best” repair of femoral hernia: mesh plug. Lapscope repair- currently not very popular.

Message: tailor the repair to the hernia, know and master a few methods.

Colorectal

Nothing new under the sun. Beart (from LA) said that the mesorectal excision for ca rectum “advocated by UK and European surgeons- is nothing new: this is how we were doing it for many years…” But this is the way to do it.

Surgical education

“we produce too many surgeons to enter a too congested market…must emphasize quality over quantity..” HMOs make education more and more difficult. Five years of general surgery prior to plastic or cardiothoracic training is a waste of time. Two years may suffice.

Computers

There are excellent software develop especially for surgeons. Amazing performance. Voice recognition technology is here. You can dictate directly into your PC; saves time and money and typists (more unemployment?)

Dr. Anna ledgerwood from Detroit gave an excellent lecture entitled: “with liberty and justice for all”; about how to prevent and deal with litigation in trauma practice. received a prolonged standing ovation. Interestingly, a day later professor Veronesi from Milan -the great innovator of breast conserving surgery received no standing ovation at all. why?

Fluid resuscitation in trauma Ken Mattox: less is better; Jim Holcroft: the conventional is best; Mike Shabot: superoptimization is out; Mitch Fink: Swan-Ganz is not accurate in trauma patients-gastric tonometry may be better.

Message: Choose the middle way; do not over and under resuscitate; maintain BP under 100.

When to convert during laparoscopic cholecystectomy? After 15 minutes of Dr. Strasberg’s talk the answer was :” whenever dissection is difficult”. A more important message was however that many CBD injuries occur AFTER CONVERSION. The invaluable options of subtotal or partial cholecystectomy in this situation was emphasized.

Small bowel obstruction:

Use of lapscope in selected patients was advocated (i.e. when it is predicted that adhesions are be localized and easily lysed- for example after an appendectomy).

No need to lyse all adhesions only the obstructing ones. Do not repair serosal tears- it will produce more damage -more adhesions.

Long tubes ?

Complete clinical and radiological (i,e, no air in large bowel) obstruction no role for conservative Rx-operate! Partial obstruction- opens spontaneously in 80-90 %; complete obstruction needs operation in 80-90 %.

Early postop obstruction- wait for 10-14 days; it will open (Jack Pickelman’s study)

In the rare case postop case when you go in and find a horror of vascular adhesions and each movement creates an intestinal hole. Close up and start TPN; after a few months it will all resolve!

Radiation enteropathy: resect the involved segment if possible. A large irradiated loop in the pelvis: bypass.

Breast: Veronesi’s lecture: ” the very early ca breast (i.e. mamographically detected-under 1 cm’) represent a local disease and is CURABLE by surgery. Bigger tumors represent systemic disease. Thus both the “Halstedian” and Fisher’s theories are true in the different lesions.

Carcinoma stomach

Brennan from NY: radical lymphnode dissection (i.e R2 resections) is beneficial based on their non randomized experience. Noguchi from Japan: extended surgery beneficial (including “total LUQ resection”)..based on the Japanese non randomized experience. Dr. van der Velde report of the large Dutch prospective randomized study: radical LN dissection= more postop M & M -not translated into improved long term results.

Upper partial gastrectomy is a “bad operation” : total gastrectomy for the high lesion is better. For the lower lesion partial gastrectomy is preferred.
Message: LN dissection may be beneficial in subgroups of patients (i.e T1-2, N1?) if performed by well trained surgeons. In the US only 5 % of surgeons perform extended gastric resections. A large multi-center (international) trial is needed to solve the controversy.

Exhibition: as always; growing square miles of sale men demonstrating recent electronic and technological gimmicks of the industry. Hysterical surgeons shopping around in an attempt not to be left behind.

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