Making of a surgeon

Residency is a job. Not a primary educational pursuit.
Residency is a passive system that depends on the patients that come
through the door.
Deliberate practice.
Currently limited in surgical training.
Surgical rotations do not allow development of mental models and
pattern recognition of surgical disease.
Medical school tracks surgery vs medicine.
- move basic science to undergrad.
- more opportunities for lifelong learning

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Laparoscopic Surgery for Crohn's disease

Possible challenges to laparoscopic surgery in Crohn's disease:
- Inflammatory mass
- abscess
- anatomical orientation: previous operation, fistualous connections
- adhesions
- difficult dissesction
- bleeding high conversion rate

Patient preparation:
- Drain abscess: keep drain until time of surgery
- Optimize nutrition with elemental diet (preferable over TPN)

SB resections:
- if single site can consider intracorporeal anastamosis
- if multiple sites will be faster to exteriorize each site

conversion to open procedure is not associated with an adverse outcome.

Laparoscopic resection only accounts for <10% of crohn's resection
-no impact on Long term QOL or function.

Surgery for Colonic Crohn's Disease

Segmental vs total colectomy:
- distribution of diseae: previous or concurrent SB disease
- status of rectum
- age of patient
- rate of recurrence

- don't leave your anastaomosis next to the duodenum; if recurrence forms develops a duodenal fistula
- Transeverse colon disease: segmental transverse colectomy results in huge mesenteric defect; better to do subtotal and anastamosis to sigmoid colon
- multisegmental pancolonic crohn's: consider IRA if pts sphincter fxn will tolerate

Immunomodulators and their impact on Surgery in IBD

Do immunomodulators increase risks of surgery?
- no good prospective studies on this topic
Appau etl al, J Gastrointest Surg 2008: Effects of infliximab on ileocolic resection
- use of steroids in non-infliximab group higher
- rate of sepsis and readmission higher in IFX group
- trend toward leak and reoperation in IFX group
Columbel et al, Mayo Clinic
- no difference in septic complications after use of IFX, AZA/6-MP/MTX, steroids
Kunitake, J Gastro surg 2008
- no significant difference in complication rate.
Therefore, conflicting data on whether they cause complications
- all retrospective and had methodological flaws
- One speaker suggested that pts of on combinations of IFX and steroids are at risk of anastamotic leak.

When should you stop immunomodulators?
- if attenuation to IFX, consider trying a 2nd biologic
- for fibrostenotic disease, will need surgery
- worsens obstruction as quick healing results in worsening of fibrostenotic disease
- stop if develop abscess
- failure of 2nd biologic
- always worry about possibility of malignancy
- stop 1 month prior to surgery: OK to continue AZA/6-MP/MTX until date of surgery

Laparoscopic IPAA

Options include:
- open laparotomy
- Lap assisted: mobilize colon laparoscopically and use low phannenstiel incision for extraction and creation of pouch
- Hand-assisted procedure
- completely laparoscopic - extraction site through ileostomy site (need normal BMI)
- single incision:

5 step Lap Total Colectomy - IPAA:
- mobilize left colon
- mobilize right colon - preserve ileocolic vessels for pouch
- rectal dissection: - uterus suspended with suture and sponge stick in vagina
- exteriorization of colon through ileostomy site: pt must be thin, bowel must be prepped
- anastamosis

Dr. Marks steps:
- takes infra colic
- takes ileo-colic vessels and divides ileum early so by end of case has sense of blood supply
- mobilize right colon
- middle colic division (branches ~3.5cm from take-off of SMA)
- divide omentum/supracolic dissection
- Closckwise rotation of cecum upto LUQ - allows you to follow the mesentery down to rectum
- pelvic dissection
- uses 30mm stapler coming vertically from supra pubic port site

Gaining length on SMA. 
- fenestrate SB mesentery

Medical Management of IBD

UC Remission:
- Aminosalicylates:
- can give oral or topically or combined
- Pentasa has earlier release in stomach and SB vs. Asacol and sulfasalazime which are activated more in the colon
- ensure that patient has had an adequate dose prior to declaring the patient has failed on this treatment
- Steroids:
- Immunomodulators:
- cyclosporine: small percentage of the population who have fulminant disease as a bridge to early surgery
- azathioprine/6-MP: steroid refractory patients

CD remission:
- 5-ASA
- Antibiotics
- Steroids: Budesonide - 9 mg: long-term therapy has fewer cushingoid SE but still at risk of osteoporosis

infliximab:
- SE: lymphoma, TB, death
- Present, Et al NEJM 1999; infliximab for fistulizing crohn's disease
Methotrexate:
- complication profile is significant and not generally used often

Indications for surgery:
- failure of medical management: make sure pt just doesn't need better monitoring of taking meds
- obstruction
- bleeding
- perforation
- CD: not operating for cure; managing complications and QOL

Risk of Malignancy:
- UC after 10 years needs 4 quadrant biopsy every 10 cm
- DALM: unless adenoma like then likely requires resection.

Laparoscopic Resection for IBD

General Principles:
- Ensure that you review pathology to differentiate CD from UC

- Perianal disease is a red flag for CD. 

- however, may be coincidental, biopsies of local fistula may not differentiate

- increased perioperative morbidity in pts on Remicaide

- Safest approach would be to perform total colectomy to get better pathology and return to fight another day.

Chronic Crohn's Colitis:
- NEVER do a segmental resection
- Controversy regarding reconstruction, IRA can be considered in select patients with rectal sparing.  Pt must be informed that inevitable re-resection of rectum is likely.

Chronic Groin Pain After Hernia Repair

Definition: Pain that lasts > 3 months after a hernia repair
- 5-7% with groin pain will go to litigation

Management of inguinodynia:

- NSAIDs

- Pain clinics

- nerve blocks

Ref: Palumbo et al, "for algorithm for management of persistent groin pain

Risk factors for groin pain:-Recurrent hernia
- high pain scores at 1 and 6 weeks

Types of Post-op Pain:

- Nerve pain. Burning

- Somatic pain. Gnawing

- Testicular pain

Nerves to take into consideration:

Considerations in Inguinal hernia repair:

- Type of mesh. Heavy vs light weight

- Fixaton: Fibrin sealant vs. Staples vs. no fixation

- Most studies have not shown a difference in chronic pain scores based on type (if any) fixation

Use as few tacks as possible and stay above iliopubic Tract

References:
- Courtney BJS 2002. Large Scottish population study
- Grant BJS 2004. Open vs lap hernia numbness and pain is initially lower in the laparoscopic group but  equalize at 5 years
- Eklund. BJS 2010. Chronic pain: At 9 years tep group few have residual pain compare to open group. Low BMI, improvement in function pre to post op lower risk of groin pain.
- Matthews. Am j Surg. 2007. Followup va study. Chonic groin pain

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Loss of domain defects in obese patients

Ching Surg endoscopy 2008
Comparison of early outcomes
Recurrence is not influenced by obesity. Recurrence related to defect
to mesh size.

Conflicting data.
Some think recurrence rate higher in obese

Concept of end stage hernia.

Options
Open inlay or onlay
Stoppa
Component separation
Laparoscopic
Combined with bariatric procedure

Contraindicatipmd to laparoscopy:
Loss of domain
Vet large defect >20 cm
Past or present mesh infections
Contraindicatipmd to synthetic mesh
Skin changes over hernia sac
Need to remove old mesh

chang archives ofaurgery 2007. Autologous recontruction.
- compontent separation 3% recurrence rate.

Should ventral hernia repair be delayed in obese patients.
- attempted medical weight loss.
- bariatric procedures.
Not known at this time.

Eid. Surg endocopy. 2004.
Repair of ventral hernia in morbidly obese.
-primary repair high 22%
- biological mesh no recurrences at 1 year
- high rate of sbo if adhesiolysis performed in hernia sac.

Staged repair may improve outcomes
Obesity is a contraindication.

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Difficult Ventral Hernias

Principles of hernia repair:
- Mark grid on skin to keep you honest where pulling out anchor stitch.
- Grid markes 4 corners of defect making sure that they bisect the defect in half.

- Most accurate defect measurement is with abdomen insufflated and form inside. Large BMI makes external measurement more inaccurate.

- Lower risk of infection laparoscopically.

- # of anchoring sutures: 4 corner sutures is sufficient usually. Larger luminous hernias probably need more tacking sutures. They are the only full thickness transabdominal fixation. Make no apologies to pt that it causes pain.

Subxiphoid hernia:
- secondary to cardiac surgical incisions
- difficulty arises in achieving adequate overlap of mesh over defect due to rib cage and diaphragm.
- May need to compromise lateral suture bc limited by costal margin.
- order of placing tacking transabdominal sutures: sup, far lateral, inf, near lateral
- may have difficulty passing superior tacking suture: Gore suture passer can be placed through the xiphoid process.

Suprapubic hernias:
- Trocar placement from above
- 3 way foley to fill and drain bladder. May need to talk to pt about bladder mobilization and injury
- 4 cm over lap below pubis
- Anchor inferior, far lateral, superior then near lateral.
- Cardinal suture into pubis periosteum. Overlap below pubic bone.
- Four bone anchor sutures placed through the pubic rami and tack down around circumference of mesh

- Bone anchor drilled. Same as flank hernia. Permenant bone anchor stitch with #2 polyester u stitch through pubic bone and mesh.

Flank hernias:
- Mobilize retroperitoneal sutures to bring out lumborum suture.
- Bone anchors into iliac crest.
- PTs on immunoauppressants may not hold bone anchor.
- PTs may get neuralgia.

Chronic pain:
Waits 6 weeks before doing anything
Injects marcaine. Usually from a tacking clip they have never had to remove stitch.

SAGES: operative cbd stones and preop ercp

Guidelines for cbd stones.
No consensus as for best treatment
Nothing
Preop intraop postoperative ercp
Open cbde
Lap cbde
Biliary drainage

50% of preop ercp pt have no cbd stones varia lancet 1999. Br j Surg.

Liberman costs lower for lap cbde. Vs ercp.
Need special equipement.

5th trocar at site of IOC. Midclsvicular line. Can not grasp cholesochoscope with grasper.

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SAGES: rationale behind cholangiograpy

'perfect' chole
- complication does not occur
- symptoms are resolved after surgery
-

Rationale against IOC.
Stones infrequent or will pass
Increase or time and case cost
Possible cbd injury
Pancreatitis
Therefore selective IOC best

Rationale for IOC.
Cbd stones can cause trouble.
Allows lap cbde which saves $$ look for berci reference.
Prevents unnecessary cbde. ? Historical. Cbde was more common in open era.
As cbde exploration was higher
Ercpist may not want
Ercp may not be available
Decrease CBd injury
Interpretting cholangiograpy takes practice and can help understand biliary anatomy

Only one constant in cbd sigmoid curve where cbd form lhd.
Rhd an cd gets plugged in at various levels.
There can be subsegmental ducts in addition to rhd.

Special situations.
Surgical clips can cause stricturing.
Bilomas can cause compression and 'stricturing'

Duct of lushka does not exist sub vesicular ducts or segmental posterior ducts.

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Management of the Difficult Acute Cholecystectomy

Fundus First Approach:
- Difficult and cirrhotic livers fundus first approach.
- benefit with Fundus first approach is that there is no need to retract heavy liver.

Subtotal Cholecystectomy:
- Remove all stones.
- Can try closing the gallbladder with sutures.
- Even leaving open and placing a subhepatic drain to form a controlled fistula which should closed on their own.

Myoma screw retraction:
- OBGYN instrument 
- Can be used to screw into tough gb that you can't grasp.

Bleeding:
- Place a 5th port to perform pringles

Be Wary of Posterior segmental Hepatic duct on the liver bed:
- Stay as close to wall of gb as possible.

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SAGES: pitfalls of lap choke andCBD injury

Cbd injury Is a HUMAN Pitfall!
If there is difficulty finding cystic duct 34% cbd injury
- you WILL have cbd injury over time. Can't avoid it but be prepared for it.

Anatomy.
Most dangerous is sliding down of hepatic duct division, cystic duct
Triangle of calot is not necessarily an area of safety

If difficult consider top down dissection
Gayet believes true triangle is right up to the junction of the gallbladder wall and the liver bed.
He has never seen a true duct of lushka. If there truely is a lushka then you should have a hole in the gallbladder wall. Likely a accessory duct in liver bed

Anatomic variations that cause pitfalls.
Short cystic duct
Narrow cbd mimiking cystic
Accessory duct in bed of liver
Tortuous cbd
Sliding bifurcation



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SAGES: Esophageal Cancer

In japan gastric cancer 90% SCC
- 3 field LN dissection (upper abdominal, thoracic and upper mediastinal)
- Ropeway technique
- Prone esophagectomy

Laparoscopic technique for obstructing cancer

Workup.
Axr
Ct

Obstruction more common in left sided tumors
Options.
Ostomy
Multistage open resection
Subtotal colectomy
Stenting as a bridge to laparoscopy

Stenting has a high rate of success
Risk is ~4% of perforation converting the lesion to a t4 tumor.
- depends on site of perforation. At tumor site upstage. Cecal perforation for sigmoid tumor not considered an upstage.

Higher risk of complication in non-ercpist endiscopist

Us there a rusk of tumor cell dissemination after stenting? There is but the clinical revalencr of this is currently unknown. Increase serum cea and ck20.

Chemotherapy may increase stent complications.
Bevacizumab increased perforations if used within 6 weeks of surgery.

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Laparoscopic TME

Classicc trial. Validation ongoing
Guilou lancet 2005

Main reason for conversion is tumor fixation.
- emphasizes importance of MRI in preoperstive evaluation.

Unfortunately classicc trial didn't demonstste short or long tern quality of life or sexual function. Marginal shorter LOS.
Main advantage is 2% hernia rate.

Classicc trial has shown feasibilty.
Ongoing trials needed to confirm efficacy.
40% of patients in France with rectal cancer are operated laparoscopicakky. Panel agreed would not choose to randomize vs open.

Technique. Strasbourg France
3 dimensional retraction principles- heald
- gauze retractor to achieve this
- articulating instrumnts?
- bipolar vs scissors with monopolar cautery

Option for hybrid lap surgery to take down splenic flexure.
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Advanced colorectal tumor resection

3 scenarios

Unresectable primary and/or mets. Asymptomatic - chemotherapy.
- in absence of obstruction or bleeding then palliative chemotherapy is entirely acceptable without taking out primary tumor.


Unresectable primary and/or mets. Bleeding or obstructive- surgery

Resectable primary with mets - two stage primary then mets vs. One stage primary and mets

Lap tips
Anchor ports to prevent rapid desufflation.
No touch technique.
Extraction site wound protector.
Make extraction site big enough to get tumor out.
? Rinse abdomen, instruments and wound with 1:9 betadine?

Gastric cancer issues

Staging is very important tumor depth and ln involvement. Eus, ct scan.
- one issue is how accurate is standard eus in determining true depth of invasion in early gastric or esophageal cancer. Does gistopathologc characteristics impact on likelihood of missed positive LNs

Neoadjuvant chemotherapy. Magic trial vs chemotherapy and rt

Lymphadenectomy. 16 ln needed. In west d2 has not been shown to be of benefit. And adds morbidity

Extent of resection.
- total gastrectomy vs subtotal/pylorus preservig gastrectomy.
-

Anastamosis and reconstruction technique.
In japan b1 or RenY, Korea b1, edm RenY
- hamdsewn vs linear stapler vs Orville endoluminal stapler.

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SAGES: laparoscopic gastric cancer

Korean surgeons use suture around round ligament to retract left lobe. Mostly for pyloric dissection. Still need fan retrator for cardia dissection.

Pylorus preserving gastrectomy. Slightly better function than total gastrectomy. Tumor needs to be at least 6 cm from pylorus. No risk of level 5 ln mets because leaving behind right gastric artery.

Gastric resection 16 or more ln needed for oncologic assessment.

Laparoscopic gastrectomy 50 cases required to attain learning curve.

SAGES: early gastric cancer

Early gastric and esophageal cancer is rare with adeno. But much higher in scc. T1a n0 0% vs. ?50%

T1 n1 cancer. What is proper surgery?
Total gastrectomy.

Superficial esophageal cancer. T1b associated with 20% LN mets. Even pts with N0 disease can be associated with recurrent metastatic disease. Morphology and poorly differentiated associated with higher recurrence.

Endoscopic mucosal resection of superficial esophageal cancer. Consider as A big biopsy. May be more accurate then conventional eus
- high frequency eus may be better at characterizing depth of onvason butnoy universially available.

Hulscher nejm 2002: trans thoracic vs trans hiatal esophagectomy.
- siewart classification


- principles of esophageal cancer surgery.
- what is the risk of Ln mets?
- if low, resection techinque does not need to focus on ln retrieval (trans hiatal may be an option) but how much do you trust your preop t staging sensitivity?
- if high look for techiniqye that yields more ln- ie trans thoracic technique.




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Common Bile Duct Stones

Indications for intraoperative cholangiogram

Always (GL):

- teaching purposes, keep laparoscopic skill set up

On Demand:

- ....

Cameron:
- if CBD stones seen on cholangiogram:
- if <2mm try flushing with saline +/- IV 1-2mg glucagon
- if >2mm, will the stones pass on their own? <3mm and unable to flush stone out
- +/- post-op ERCP

- when should laparoscopic CBD exploration or open CBD exploration be performed?
- >3mm
- or do you arrange post-op ERCP?

Laparoscopic CBD exploration options - transcystic:
- wire and fogarty balloon flushing
- laparoscopic choledochoscopy
- Laparoscopic choledochotomy is much harder and depends on amount of inflammation
- unlike open CBD exploration, stay sutures are no needed
- choledochoscope is passed through mid-clavicular line 5mm port site
- choledochostomy closed over T-tube although primary closure has also been described

Open CBD exploration:
- lateral stay sutures
- 11 blade to open CBD longitudinally about 1.5 cm.
- the further distal the better so that you are away from the confluence of the hepatic ducts
- options include: choledochoscope, flushing, fogarty balloon, randall forceps followed by flushing, bakes dilators
- closure of CBD is usually done over a 14Fr T-tube which is left in for ~3 weeks. + JP in hepatic bed
- manage by doing a choangiogram then clamp T-tube.  IF no leak in JP then pull JP prior to discharge
- leave in for 3 weeks and pull T-tube in the office (+/- another cholangiogram in the office)

Graves disease

Indications to operate for graves disease
Suspicious nodule
Large goiter
Pregnancy <6mos
Eye signs
Poor compliance with Meds

Zollinger-Ellison Syndrome

Triad:
- gastric acid hypersecretion
- severe PUD
- islet cell tumors

- Rare, 50% are malignant

Diagnosis:
- serum gastrin off PPIs
- secretin stimulation testing
- Basal acid output
- Somatostatin Receptor Scintigraphy (localizes gastrinoma in 85%)

Passaro's Triangle: (70-90% of gastrinomas will be found within these limits)
- cystic duct
- 2nd/3rd part of duodenum
- jxn of head and body of pancreas

Rule out MEN1 prior to OR:
- in MEN1 pts resection rarely normalizes gastrin levels and does not affect long-term survival
- manage hypergastrinemia with very high doses of PPI
- in comparison sporadic cases should be treated aggressively with surgery as 50% 5-yr disease free survival

Surgical Management:
- warranted in absence of metastatic disease
- sporadic gastrinomas
- resection will largely depend on site of tumor
- limited hepatic resection for mets may be considered
- if widespread disease may consider vagotomy and antrectomy to avoid need for long-term PPIs

Multiple Endocrine Neoplasia Syndromes

MEN1: (P followed by a vowel)

- Pituitary (anterior) tumors

- Parathyroid hyperplasia

- Pancreatic islet tumor

MEN2a: (2 MPH)

- Medullary Thyroid cancer

- Pheochromocytoma

- Hyperparathyroidism

MEN 2b: (3M Plastics)

- Marfanoid

- Mucosal neuromas

- Meduallary thyroid cancer

- Pheochromocytoma

Adequate Thyroid FNA sample

Criteria for cytologic adequacy of thyroid FNA:

- 6 follicular cell groups
- each containing 10-15 cells
- from at least 2 aspirates of a nodule

DDx: Elevated Gastrin Levels

GRAZ RAPPS:
- GOO
- Retained antrum
- Antral G cell hyperplasia
- Zollinger-Ellison Syndrome

- Renal Failure
- Atrophic gastritis
- Pernicious anemia
- Previous vagotomy
- Short gut

Thyroid Ultrasound Characteristics suspicious for malignancy

- nodule Hypoechogenicity
- Irregular infiltrative margins
- increased intranodular Vascularity
- presence of microCalcifications
- an Absent Halo
- shape Taller than the width measured in transverse dimension

G-tube (GL)

Upper midline incision:

1) places purse-string suture around anticipated site of gastrostomy (2-0 PDS box-stitch)
2) opens stomach and places malecot (16-18 Fr)
3) brings malecot out through skin
4) prior to bringing stomach right to abdo wall places 4 anchoring stitches (2-0 PDS) in 4 quadrants to secure antrerior wall of stomach to anterior abdominal wall