Surgery Blog for Surgeons

Along the way we shall catch excellence...

Aiming at excellence is the natural goal for a lot of activities in people's lives. Our work is just one, granted a very important, aspect of this process.

Dr. Aloia from the MD Anderson Center in Houston just achieved a point on excellence by publishing a paper about striving for "Zero Harm".

One may not thing of this goal as being a problem but he outlines several issues along his path of improving his outcomes after liver resections. Going for a "Zero" complication rate leads to:

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Can we ligate the celiac trunk?

Branches of the aorta used to be considered vital for the circulation as they often supply a large amount of other vessels. Ligating intercostal or lumbar branches is commonly accepted to be safe if needed. However, the major ventral branches of the aorta were generally thought to be more important. Occlusion of the inferior mesenteric artery (IMA) is being practices routinely ever since the introduction of the endovascular aortic aneurysm repair (EVAR) with often only transient mucosal ischemia of the sigmoid colon observed in about 10% of the cases.

While the occlusion of the superior mesenteric artery (SMA) is widely accepted not to be compatible with life, ligating the celiac axis may be an interesting approach to explore.

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Laparoscopic vs. Open Resection in Rectal Cancer

Open low anterior resection (LAR) and abdominoperineal resections (APR) are not easy procedures, esp. in tight male pelvises. The laparoscopic approach gave us a tool dramatically improving the exposure and making the whole mesorectal excision significantly easier. As frequently in situations like that, we were quite hopeful (and meanwhile biased towards believing) that the advantages in the laparoscopic LAR and APR would translate into better oncological outcomes.

Dr. Fleshman (Dallas, Texas) was one of the most vocal proponents of the laparoscopic approach and wanted to prove it. He recently published a very well designed study:

Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes
The ACOSOG Z6051 Randomized Clinical Trial

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Surgery podcast

Podcasts are regaining attention after the initial hype in the mid 2000s and the subsequent decline of their popularity. I've always thought that podcasts are a great resource for gaining or maintaining knowledge.

Looking for a good surgery podcast, the residents in the center I work in recommended Behind the Knife (BTK). I gave it a try and was pleasantly impressed. It's not ideal but it is very good and well made. In addition, the guys running it, put a great effort in engaging nationwide renown surgeons.

All kind of topics are discussed in BTK incl. ABSITE and Board reviews but also review and analysis of important literature.

I intend to use some of the episodes for complementary information whenever I write about a particular topic.

Here is another list of the episodes and this one offers easier downloads.

Have fun!

How to close a midline laparotomy - The STITCH trial

A lot, maybe even the majority, of things we do in medicine in general and in surgery in particular, are not evidence based. One of those things, no being supported by good data, is one of the most commonly performed procedures in surgery - closing of the abdominal midline incision.

There is some data supporting the 10mm/10mm running closure with PDS 1 suture. However this data is quite weak and now finally somebody decided to challenge that.

Even before this trial, there was evidence that smaller stitches with a more gentle suture would achieve better results in terms of preventing hernias. However, this paper describes the first double-blind, multicentre, randomised controlled trial addressing this question:

Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial, Lancet. 2015 Sep 26;386(10000):1254-1260. doi: 10.1016/S0140-6736(15)60459-7. Epub 2015 Jul 15

Here I'm sharing some thoughts about the trial and its critics.

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(Ab)Using scientific journals for political purposes

I just read the article "What Liver Transplant Outcomes Can Be Expected in the Uninsured Who Become Insured via the Affordable Care Act?" in the last edition of AJT and would like to share some thoughts about it.

Cohort selection

On page two the authors write:

All charity care candidates were rigorously screened by social workers and neuropsychiatric professionals to ensure that they have 1) a strong social support system, 2) a failsafe transportation mechanism to facilitate access to posttransplant clinics, 3) adequate cognitive function to understand the transplant process, and 4) a personality that predicts that the candidate will be reliable to take medications as prescribed and come to clinic appointments as required.

Besides suggesting high preselection bias of the patients in this group, one would wonder whether the protocols in Alabama don't include this kind of evaluation of all patients and not just of the ones who are uninsured.

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"First pass" mesenteric flow is not necessary - portal vein arterializaton

Portal vein thrombosis (PVT) is such a profound problem that it has been considered to be an absolute contraindication for a liver transplantation (LTx) and I know centers still denying LTx for patients with PVT. In the most cases the donor portal vein is anastomosed with the superior mesenteric vein (SMA) of the recipient using a vascular graft (usually from the same donor). There are some reports about porto-renal anastomoses. The portal vein arterialization (PVA) is the option which recently attracted my interest and I took a look at what was written about this.

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Brenner Tumor

In 1907 Fritz Brenner published his thesis "Das Oophoroma folliculare".

F. Brenner: Das Oophoroma folliculare. Frankfurter Zeitschrift für Pathologie, München, 1907, 1: 150-171)

He described what was later called "Brenner Tumor".

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Single Incision Laparoscopic Surgery (SILS)

The initial hype about NOTES is over!

This is such good news that I couldn't resist starting with it. :)

I wrote twice about this topic and not only my opinion didn't change, I noticed that the general perception regarding NOTES is meanwhile clearly negative. Even people who are usually more open to new approaches share this position now.

Surgeons need new challenges though and the Single Incision Laparoscopic Surgery (SILS) is offering some. Recently I was on Grand Rounds where a general surgeon from a private practice shared his thoughts and experience with the auditorium about SILS. I was hoping that he would focus more on review of the (still scarcely) available data. He decided to just present some of his cases though: just cholecystectomies.

Here are my impressions from this talk:

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