Thursday, June 23, 2005

The Search for Laparotomus Rex....
Aggravated Doc Surg has an excellent analysis (included in what even I have come to realize was an overly-long Grand Rounds) of an editorial in the June issue of the Journal of the American College of Surgeons($):Enough, but Not Too Much: Or, Are We the Dinosaurs? Laparoscopy has almost taken over:
The effects on our training programs are as yet unknown, but the shift from open techniques to minimally invasive surgery has been tremendous. The archetypal example of the latest impact of minimally invasive surgery is the effect laparoscopic approaches have had on bariatric or obesity surgery. The American Society for Bariatric Surgery has grown in membership from 258 in 1998 to 1,070 in 2003; the number of bariatric procedures in the US has grown from 16,000 in the early 1990s to a projected 144,000 this year Laparoscopic, minimally invasive procedures have made this the fastest growing area of surgery.

Although the data show that open, tension-free mesh hernias are an excellent and cheaper form of hernia repair, laparoscopic hernias are growing in popularity. In some hospitals, up to 50% of appendices are removed laparoscopically, more than 75% of gallbladders are taken out through a scope, and many diseased, nontraumatized spleens are removed minimally invasively. Laparoscopic colectomy has proved to be acceptable for cancer, and laparoscopic donor nephrectomy has become the procedure of choice for living donors.
As my colleague points out, nobody expects to convert to open:
For example, does the average surgery resident finish training with many common duct explorations? Open Nissens? Open cholecystectomies? This is not a moot point, as the "easy" cases will always be done laparoscopically --- when we convert to an open procedure, you can bet that it is because the operation is much more difficult, due to anatomy, bleeding, etc
Conversion is not all that rare a phenomenon:
Conversion rates for procedures vary significantly according to procedure, operator, and high-volume versus low-volume centers. Studies from several countries give a conversion rate from laparoscopic to open cholecystectomy at 9.5% to 4.8%, with an average of 5% to 10%. That means that an average chief resident will do between 5 and 10 open gallbladder procedures during residency. In a recent study from Italy, the conversion rate for appendectomy was 9.7% because of severe peritonitis or anatomy. Gastric bypass conversion is down to 3% according to a recent study. Hernias and adrenalectomy rarely need conversion, and left colectomy required conversion in 4.9%. The US randomized colon cancer trial had a 21% conversion to open rate among laparoscopic colectomies. Even perforated gastroduodenal ulcers need to be converted to an open procedure only 12.5% of the time.
My program was unusual in that we had an attending that did not believe in laparoscopic cholecystectomy. He would do his through a mini-lap incision. While we all kind of laughed behind his back but we did learn how to do an open cholecystecomy. We would tell residency applicants that if they came here they would have more experience with open cholecystectomy than almost anywhere else. Looking at my submitted numbers from residency (lower than actual because I lost quite a number of the "checkbooks" we used to record cases) I either performed or served as teaching resident on 41 open procedures and 166 laparoscopic ones. I didn't finish my surgery residency that long ago,either. Only a handful of those were conversions. Moving along:
We have established learning curves for many laparoscopic and now for robotic procedures, but the question for the educators of future surgeons has to be: How many open procedures do you need to do to be safe? Ramifications of this include a revision of Residency Review Committee requirements for procedures, a revision of the oral and written boards, and a new definition for general surgery. Why do we need fellowships in advanced laparoscopy or even bariatrics if the current trend toward laparoscopic surgery continues? The attempt to pull out the cardiothoracic and vascular trainees from general surgery makes absolute sense if the majority of senior surgical residency is spent behind a camera.
Sound like film school. Another argument for specialty track. The generation gap rears it's head:
So let us look at facts: The majority of the leaders in American surgery were trained in the era when minimally invasive surgery was in its infancy. The new directors and chairs are coming in at a time when the “open” Nissen is an anachronism. How many chief residents know how to perform a common duct exploration? (Do they need to?) Giving the oral boards recently, I was amazed to find that the treatment for a strangulated inguinal hernia requiring a bowel resection was “vicryl mesh,” because very few knew what a McVay repair was. The treatment of choice for a perforated ulcer was a laparoscopic repair. The number of open gastrectomies was about equivalent to the average number of “Whipples” performed.
Nowargumentgument has more to do with the widespread use of open prosthetic hernia repair techniques than the popularity of the laparoscopic hernia repair.
How many “open” ventral hernias does the up-and-coming resident need when he can take down adhesions with scissBobbieor bovie or harmonic scalpel) through a scope? The question becomes more important as fellowships turn out more advanced laparoscopists who will, in turn, teach residents more advanced techniques. The new generation of laparoscopic surgeons, through a combination of patience, guts, and skill, can complete the majority of operations and address complications without opening the patient. Who would have thought that you could patch a laparoscopic gastric bypass leak laparoscopically and avoid a laparotomy most of the time? What will happen to surgeons who have seen 200 laparoscopic appendices, hernias, and gastric bypasses, who realize that they can’t do a procedure safely through a scope because of inflammation or bleeding? Will they be prepared for the open procedure?
[emphasis mine]

My take: Laparoscopic cholecystectomy has a well-proven track record of safety. It has advantages of reduced pain, reduced stay in hospital, and earlier return to activity.

In my hands my open appendectomy patients are discharged the next day, have good pain control, and return to normal activity (excluding heavy labor) in a few days. I myself cannot justify the added expense of the laparoscopic procedure given the results. YMMV, however. Further thoughts here.

I reserve laparoscopic inguinal hernia repairs for recurrent hernias (the anatomy is less distorted) and for bilateral hernias (pain control). Otherwise I perform a "plug-and patch" via an open anterior approach.

Laparoscopic ventral hernia repair allows for full visualization of defects. Useful in the "swiss cheese" scenario of several small defects. Recurrence rate is reduced, but LOS/pain control about the same between the procedures.

Still on the learning curve for laparoscopic colectomies. LOS and pain control eqivalent to the open procedure.

My partner does laparoscopic Nissen fundoplications, adrenalectomies and a few splenectomies. He is pleased with the results compared to open operations.

Neither my partners nor myself perform bariatric surgery, open or laparoscopic.

The solution? From the editorial and ADS's post:
We propose that the RRC (Residency Review Committee) and the American Board of Surgery look at their requirements for essential cases and revise them to reflect the rapid rise in minimally invasive techniques. We can find no data on the number of open procedures necessary to make a competent surgeon, only total numbers. The RRC doesn't even require "advanced" laparoscopic cases. We need to talk to the young surgeons and the experts who perform primarily laparoscopic procedures, and ask what is necessary to train the general surgeon of the future. If general surgery is to survive, minimally invasive bariatric procedures, splenectomy, Nissen fundoplication, and colectomy need to be taught in residencies. We still need to teach surgeons how to do a hand-sewn anastomosis, close an incisional hernia, and take out a gallbladder through an incision, just in case there is a reason to abandon a scope and do it the old fashioned way. Oh yes, and do this in 80hours a week.
In the best of all possible worlds, newly minted surgeons would take jobs with older, more established surgeons that provide expertise and help ("mentoring," to use the current buzz word) -- here, again, I was and continue to be extremely fortunate in this regard. That is probably not attainable for many graduating residents. It is hard to conceive a situation where the RRC would mandate a certain percentage of cases to be done "open," either: can you imagine the consent form for patients at teaching facilities then ---- "if we determine that the resident helping with this operation has insufficient experience with the open technique, you'll get a bigger incision." That would be about as popular as Howard Dean at a NASCAR event.
Yeah, try to get that consent signed.
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