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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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.

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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