What’s new in surgery ?
A 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.
I wondered where everyone went and suspected ACS for the city surgeons and hunting for the country surgeons–being female, I have been the only surgeon in town because of hunting for the last few weeks. I did take 2 weekends off to go to MPLS for the Colorectal and Mechanical Ventilation courses, which met with much displeasure, because they could not both go hunting at the same time when I was out of town.
Our Pathologist uses Dragon Dictate, one of the voice recognizers–the major disadvantage is that you have to talk very slowly and enunciate clearly (separate words clearly when you speak)–you also have to spend about 2 weeks ahead of time with the program so that it recognizes your speech.
It is an interesting concept on terribly vascular adherent early small bowel obstructions to just give up dissection before causing any more damage–in retrospect, I wish I had done this on a few patients.
Your report back from ACS is excellent. People who could not go appreciate very much the informations.
Thanks for the update. I am one of the “quantity” preparing for the written boards to be taken this Thursday. I read many opinions during my training regarding the number of surgeons being trained but not many solutions/action taken. Is there a definitive move to do so? It seems that medical students are being encouraged to enter primary care positions and are doing so in droves.
Surgical training is difficult but I have found out even in my first 3 months of private practice how valuable the time and effort put into that training is to taking good care of patients. However, talking to medical students during my residency (and greatly generalizing) they see shrinking re-imbursements, increasing loan debt, and long hours and figure there must be a better way to make a living in medicine a.k.a. Generation X.
Yes, the plan is to cut down on first year residents and restrict significantly the entry of IMG into US residency programs. The problem is that residents provide SEVICE in most public hospitals- replacing them with PA’s will be more expensive!
It sounds like time for Fellows of the ACS to quote the reporting of the meeting, and its popularity, on the net, and to ask the College to consider putting the text of abstracts and maybe poster sessions on a web page of theirs.
Thanks for this valuable and precise report. Could you please talk a little more about indications for LN disection in gastric cancer?
I was “surfin’ the Net” last night and ran up on the ACS Website. They have posted the summeries of presentations given in SF. They also have a lot of other info and a page of links to check out.
Two of the talks that I attended mentioned sentinel node biopsy. There was at least one other lecture which mentioned sentinel node
techniques but I didn’t attend it.
I hadn’t done a lot of reading about sentinel node biopsies prior to this meeting. The concept of initially biopsying only the sentiel node seems attractive. It could certainly reduce some morbidity of LN dissections. The technique as described by Morton looked easy (using a hand held geiger counter combined with staining). I didn’t follow the specifics of the radioisotopes or dye that was used but I figured I can look that up at a later date. Both talks reminded me of the LN dissections that I have done in which all LN were negative, and the patient suffers some morbidity from the proceedure (like prolonged seroma).
At this yrs ACS I managed to force myself to go to the whore house and spent a total of 15 minutes walking around watching the reps sell their wares and attempt to convince surgeons that they need some gimmick. All I can say is YUCK. It did little more than confirm my disgust for salespeople.
Don’t be so tuff on salespeople (my sister-in-law is in nutritional sales). A good salesperson could teach you how to use the latest gimmick for sentinel lymph node biospy and may provide you with the current lit. and a dinner.
At the American College meeting there was a booth selling a new internet based reprint service. For a monthly fee of about $30/mo. they would download the full text of articles found in a Medline search. This seems much cheaper than most of the electronic reprint services I’m aware of which charge $10 – $20 per article. Unfortunately I’ve lost their card. Does anyone know how to contact this company? Their booth was near the medical publishing area.
Unless I was missing something obvious, there were less than a dozen abstracts from the whole meeting. Conference sponsors have a lot to gain from posting at least the detailed program, and preferably all abstracts.
There are things to learn about use of devices elsewhere, trends, and of course getting samples if you are serious. Something else I would encourage colleagues to do is to visit surgical instrument factories at least once during their working lives. I’ve visited a lot in pursuing my interest in ergonomics in surgery and performance standards for surgical instruments. Once I lined up a week’s visits in Tutlingen, Germany which was great (the Hotel Shlak) had a glass box display of surgical instruments instead of the usual tourist things). In the US I’ve visited Snowden Pencer, VMUeller, Pilling, Storz, Weck, and half a dozen others and had a warm welcome in each after lining up the visit.
I visited the ACS page and sent them a mail asking about what kind of products would they put into the media ( about the Congress) like abstracts online, maybe full-articles, digests of some top conferences , or even a CD-ROM and …. NO answer till now !