Laparoscopic versus open

[Foxxy Cleopatra]

Hi-

Just curious about other's experience (and preference) for laparoscopic versus open. I came from a program that hardly used laparoscopics and now am in one that uses it widely. Do you guys see surgery trending toward most procedures being minimally-invasive?

Also, are there situations where open has proved to be superior? Do you feel laparoscopic abdominal procedures are equally as safe in the hostile abdomen (opening up someone with peritonitis, known perf, etc (post-op infection rate any different)? Anyone seen laparoscopics used in surgical oncology?

Thanks

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[supercut]

I did a visiting rotation as MS 4 at a program where one hepatobilliary attending would do an initial exploration laparoscopically for bile duct CA. The idea was to look for metastatic seeding. He'd take biopsies of suspicious areas and send them for frozen section before deciding whether to actually proceede with the operation. I only saw him do this a few times, and each time the areas he biopsied were benign, so he then opened and did the resection (or once just did a prophylactic drainage procedure becuase of the size of the primary tumor)

I interviewd at a program where one attending reportedly had done a few laparoscopic assisted whipples...most of the dissection done through the scope, then a smaller abdominal incision to remove the specimen. Frankly, I don't see the point.

 

[mpp]

Laparscopic prostatectomy and nephrectomy for cancer are performed. Urologists seem to do a lot of minimally invasive stuff.

I think laparascopy will continue to grow and there is no doubt the trend will continue towards less and less invasive techniques. There will be resistance (as there was when laparscopic cholesystecomy was a new procedure) but certain laparascopic procedures will become the norm over time.

 

[dr.evil]

As a 1st year I did a multiple laparoscopic procedures. I did countless lap appys and lap choles, a good deal of laparoscopic hernia repairs, a few lap nephrectomies, and one lap radical nephrectomy (by far the best case of my intern year). My more senior residents have done multiple lap colons, lap spleens, lap gastric bypass (roux-en-y), multiple VATS procedures, etc.

I really enjoy the challenge of laparoscopic cases. I also really enjoy a huge open belly case (fun, fun!!). I think everything is going more minimally invasive. We had a Cardiothoracic surgeon do a laparoscopic one vessel CABG with a mini (3 inch) thoracotomy. Craziness if you ask me but that's the way it's going. Hard to argue with the fact that a lap chole vs open chole means you go home the same day vs. you don't. I still prefer to have the tactile sense of an open case if possible though.

 

[ESU_MD]

I was very resistant to laparoscopic procedures at first. I had no interest in learning, much rather would like to do a big open case, like AAA, or trauma ex-lap. Basically I like blood and guts.

BUT, lap is better for outcomes and its here to stay- like it or not.

after actually getting to do some, its kinda cool. the first couple lap choles were very painful for everyone watching, but you get the hang of it quick. so far no CBD injuries.

My new goal is to be able to do lap- roux gastric bypasses by the end of 5 years. A pretty neat procedure and a rather lucrative one too I hear.

 

[droliver]

I have thankfully graduated beyond laparoscopy @ this point. I used to be impressed more by it then I was by the time I finished general surgery. For many complex procedures it seemed that all I was doing was torturing myself with longer operations when the patients really didn't seem to do that much better. Laparoscopy is a pretty big advance for gallbladders, spleens, ventral hernias, reflux surgery, gastric banding, and diagnosistic exams for abdominal pain NOS. I never saw much advantage for inguinal hernias, appendectomy (where you're sure of the diagnosis), colon surgery, nephrectomy, liver resection & RFA procedures, or pancreatic cases.

I've also come to the opinion that laparoscopic bariatric procedures (banding excluded) are inherantly unsafe because you make too many compromises in technique to get it done thru the scope that you would never accept if you did it open - I think there are a lot of surgeons who would not reccomend this to a family member @ this point in time even though its being done more widely for marketing reasons mostly. Most of you who have seen good results so far will have you enthusiasm tempered when you start seeing the leaks, marginal ulcers, & other frequent complications that go with the procedure. It took me scrubbing with a few surgeons who have done over 1000 of them (open GBP) to realize that you can do it very quickly with little morbidity thru miniscule incisions & a 2-3 day stay for most patients. For your training also, open GBP is very underated. Most residents dread them, but you get to do a number of manuevers that you incorporate into other advanced cases & trauma procedures (esophageal mobilization, gastric division/anastamosis, roux-en-y limb construction, SB anastamosis, retrocolic & retrogastric manuevers) that can really teach you a lot of anatomy. I think I ended up doing close to 50 of the open ones during my training & it was a very important part of my familiarity with the abdomen. If you get the chance to do these (and organ transplant harvests) as junior residents jump all over it!

 

[Pheo]

Good discussion on Lap vs Open surgery

Droliver - It appears as though lap Gastric bypasses are here to stay. Whether the procedure is market driven or outcomes driven I'm not really sure - all I know is that where I did my lap fellowship (Uro) they were doing about 8 - 10 a week and getting good results.
I'm in a similar situation when it comes to lap radical prostatectomies. It has yet to be determined whether this procedure is as good a cancer control operation as its open counterpart - I have my doubts. Regardless of outcomes, the procedure has taken off in several major metropolitan areas and it may be a surgery that I will ultimately need to learn how to perform.

Also, I don't remember too many miniscule incisions when I scrubbed on these open bypass cases as an intern. These incisions were actually pretty large (Chevron) and alot of these patients developed wound infections post op which is one of the advantages of the laparoscopic approach.

Dr. Evil - Did you say you did laparoscopic nephrectomies as an intern? Were you holding the camera or 2nd or 3rd or 4th assist? A lap nephrectomy is one of the most advanced lap cases out there and is invariably a Chief/Fellow/Attending level case.
Most urology residents graduate without even having done one case (as primary surgeon).


Pheo

 

[FliteSurgn]

I love laparoscopy! I am a strong advocate for doing everything that can potentially be done through the scope. Yesterday I talked the staff into doing a lap pancreatic cyst-gastrostomy. It was awesome! It took less than 45 minutes. That's faster than I could do the same operation open.

For most procedures, the outcomes are the same or better compared to the same operation done open. And as far as colon cancer goes, there is some data coming out that it is at least as good of a cancer operation. (There actually appears to be a survival advantage in Stage III disease performed laparoscopically.)

There certainly is a learning curve to the advanced procedures, but the curve is much shorter if you get a good foundation in basic laparoscopy early on. By the 3rd year, most of our residents have done a few lap inguinal/ventral hernias and yes, Pheo, lap donor nephrectomies.

While I agree with Dr. Oliver about open GBP being a great learning opportunity, I disagree with his take on laparoscopic bariatrics. In skilled hands, the laparoscopic approach does not include "compromises in technique." The problem here is the mass migration of surgeons to this field that probably shouldn't be there. When done correctly, the outcomes are similar between open and lap GBP in terms of weight loss and leak rate. Obviously, the biggest advantage of the lap approach is the lower wound related complications. Open GBP has anywhere from a 10-50% ventral hernia rate which correlates well to their higher incidence of wound infections.

Once again, I'll say that you should do what you love. If you don't love advanced laparoscopic surgery, leave it for someone who does. ME!

 

[Pheo]

I agree with Flight Surgeon in that a majority of open surgeries can now be performed using laparoscopic techniques without a compromise in cancer control and with equivalent complication rates.
There are certain procedures (i.e lap prostates) though I believe need to be evaluated in the long term in order to justify performing them. I would not mind spending four hours (open=2 hours) doing a lap prostatectomy if it resulted in a decreased hospital stay (not likely, open=2-3days) and a shorter convalescence (likely) and was equal in terms of oncological efficacy. The latter has yet to be determined.

Also. where I trained the junior urology residents were getting their hands on the lap donor nephrectomies because we did so many (>70/year). Unfortunately, the radical nephrectomies for renal masses were alot less common and invariably more difficult procedures so these were left to the upper level urology residents. I am very fortunate to have done so much lap as a Urology resident, especially compared to the other graduating residents in the DC area.

I love laparoscopy and it is one of the main reasons I was hired at my current job. Nevertheless, I think its still important to keep an open mind and evaluate each procedure individually.

Remember, just because it can be done (laparoscopically) does not necessarily mean it should be done.

Pheo

 

[droliver]

Originally posted by FliteSurgn
While I agree with Dr. Oliver about open GBP being a great learning opportunity, I disagree with his take on laparoscopic bariatrics. In skilled hands, the laparoscopic approach does not include "compromises in technique."

I'll stand my ground on this one.
1)When you do the gastro-j thru the scope it is a very hard thing many times to appreciate the tension on the limb.
2)Its easy to get disoriented with the mesentary, especially when its foreshortened
3) You cannot size the residual gastric pouch as accurately (it tends to be signifigantly larger with the laparoscope)
4) When (if) you sew the gastro-J or entero-enterostomy you handle suture in a way you'd NEVER accept when you do an open case (ie. you follow your sewing hand by grabbing the prolene with the instrument)
5) No one is going to argue that you're as precise with laproscopic sewing & knot tying no matter how good you are
6) there are concerns over the gastric division you're obligated to do with the scope in re. to ulceragenic properties

I don't mean to be a complete naysayer on the procedure, but I really did a lot of both of these & these were things that jumped out at me. When they (lap GBP) go well, you think its the greatest thing ever. Most people's enthusiasm wanes when you start to see the complications & leaks. I too have seen some of the published series showing these wonderful results, I just don't buy it & I have to wonder if their complications are going elsewhere as often happens

 

[droliver]

Originally posted by Pheo
Also, I don't remember too many miniscule incisions when I scrubbed on these open bypass cases as an intern. These incisions were actually pretty large (Chevron) and alot of these patients developed wound infections post op which is one of the advantages of the laparoscopic approach.

Pheo,

about the only thing I've ever done thru a Chevron have been liver transplants & whipples. I was doing midline open GBP thru 4-5 inch upper midline skin incisions more often then not (its a struggle, but feasible when you're determined). Most of them go home in 2-3 days except the ones with the more serious pulmonary comorbidities. When you get to that point of morbidity (or lack of it), it gets hard to justify the scope sometimes. The ventral hernia rate is a real concern, but its an acceptable trade-off for the technical part of the surgery for a lot of surgeons.

 

[dr.evil]

Pheo, I was doing the majority of the lap radical nephrectomy. I know that sounds crazy (hell, it was crazy and by far the best case I have done as a resident) but I was on a urology rotation and the attending asked "how many lap choles have you done". I had done around 15 at the time and he said "good enough". I had never even touched a harmonic scalpel until then. He had done more than anyone in town so I guess he was comfortable letting me go to town.

We do a fair amount of the lap roux-en-y GB (3-4 per week) and the method by which they are done here is very controlled, methodical and I'd say very safe. The complications so far have been VERY minimal. Clinically significant anastomotic leaks have been less than 1% over the last year. That's better than our LAR leak rate. I have not seen the sizing of the pouch to be very difficult either. I do agree that tension on the limb is a little to assess. Orientation of the mesentery is marked prior to bowel transection. Anyway, so far I have not been disheartened by the results as dr.oliver apparently has (and granted, he's been around a little longer).

Lap donor nephrectomies are definitely becoming the norm although I sure do love to do them open. Lap spleens, adrenals, Heller myotomies, Nissen's, colons, etc are all being performed at a higher rate than the sweet old open cases. We really only have one, maybe two attendings who will attempt anything lap on the freakin' pancreas. I hate that damn organ.

 

[samsoccer7]

After my Ob/Gyn rotation, I found that Lap hysterectomies, appendectomies, endometriosis fulguration, and countless other gyn problems are definitely easier laproscopically. I know we're talking gen surgery here, but just thought I'd put in my penny. It definitely gets the patients out of the hospital faster, and back to their normal activity in less than 6 weeks easily.

 

[droliver]

Originally posted by dr.evil
Clinically significant anastomotic leaks have been less than 1% over the last year. That's better than our LAR leak rate. I have not seen the sizing of the pouch to be very difficult either. Orientation of the mesentery is marked prior to bowel transection.

A 1% leak rate would be better then most published series on the procedure & certainly not attainable in most peoples hands I think. The pouch size issue is a point brought by surgeons who've done alot of these procedures via the open. Your ability to do it as accurately without the tactile feedback & positioning of the stapler just can't be done the same. When you get Upper GI's of the stomach this is a trend people have noticed as they looked @ their own laparoscopic cases. You wouldn't neccessarily notice it (except radiographically) except when these people come back with marginal ulceration from antral tissue in your pouch, this is a problem I saw 6-7 times several of which required reoperation for bleeding months after their original operation.

Dr. Evil, I think the most objective people to talk to about the bariatric population are prob. the partners of your staff who do the bariatric cases. The bariatric surgeons tend to minimize their own complications & morbidity of the procedures, while the guys who occassionally cover call for them on the weekends will tell you a completely different story. They get deluged with phone calls. At least that's been the pattern in several places I've been. A number of my staff would refuse to cover the bariatric surgeons for this very reason.

The limb tension thing bites you in the ass either early (when they leak) or many weeks/months laterwhen they have strictures requiring either dilation or stricture. I've seen several of those perforated during dilations of the stricture(from both open & lap GBP mind you).

My comment re. disorientation with the mesentary was in reference to when you get lost during you mesenteric scoring. Its very easy to devascularize the pedicled limbs of SB during this manuever. Short, fat mesenteries are very tricky in re. to this & I think this is one of the things that can get you really confused during lap. colectomies. Before you know it you staring at ureter

There is a real well-balanced symposium printed in this months Contemporary Surgery journal on the possible benefits of laparoscopic colectomy. They outline many of the fallacies of the touted benefits for many patients as well as describing some of the benefits in selected groups & some technical points about some of the more difficult laproscopic cases on the Colon & rectum. Very good read!

 

[maxheadroom]

<gag, retch, barf>

I haaaaaaaaaaaaaate bariatric surgery. The "fat pass" is one of the most evil operations ever conceived.

I once worked with a surgeon who did the open procedure of super-morbids . . . and they got sooooooo sick sooooooo frequently. It was a pain worse than death to round on them twice a day . . .

 

[Pheo]

Dr. Evil - A lap radical nephrectomy as an intern. (where were the uro residents?) That's pretty impressive. I did my first one as a PGY5 (6 yr program) and I thought that was advanced. 15 lap choles as an intern - that's also phenomenal. I remember when I was a medical student doing my clinical rotations (94/95) and seeing the Attending and the Chief resident doing the lap choles. How times have changed!

Sounds like you're getting great clinical exposure on your rotations - take advantage of it and good luck the rest of the way.


Droliver - 4-5 inches - that is small. Working in a hole is pretty painful though. I'm all to familiar with working in holes (ie RRP's). In fact I just finished a radical orchiectomy on a patient that weighed > 300lbs. We made a pretty generous inguinal incision and had to use the Balfour retractor for exposure!


Pheo

 

[dr.evil]

droliver: I totally agree with all of your statements (especially about the bariatric surgeons downplaying complications). I personally have only done a handful of these lap fat passes and will likely endure all of the complications and problems you have spelled out. That's why it's a five year program.

pheo: My program doesn't have a urology residency which is why my urology experience as an intern was so phenomenal. Now that 2nd year is underway and all of my cases are entered, I logged 32 lap choles as primary surgeon not to mention the NUMEROUS lap choles as 1st assistant. It really was a great intern year and I did an enormity of OR cases. I even did 5 lap inguinal hernias. really amazing.

 

[Winged Scapula]

Originally posted by droliver
The bariatric surgeons tend to minimize their own complications & morbidity of the procedures, while the guys who occassionally cover call for them on the weekends will tell you a completely different story. They get deluged with phone calls. At least that's been the pattern in several places I've been. A number of my staff would refuse to cover the bariatric surgeons for this very reason.

Heck - who needs to talk to the attendings? At Hershey (like many university programs), the residents take all outside calls from the operator for almost all of the surgical services (ie, if you call the operator and ask for Attending X, you will get the intern/junior resident on his service. I cannot tell you how much we hate taking call for the service which includes the Bariatric guys...almost all of the calls, especially the late night ones, are crying post-GBP patients. They all thought it would be easy, that they wouldn't have this nausea, this vomiting, this pain, these wound infections...tell me about minimizing complications.

Just had to vent (although I no longer have to take those calls)...

 

[dr.evil]

Yeah, it works the same way here. The attendings sleep like babies while I have to trek to the hated E.R. and see their patients no matter who operated on them. I've actually been the one called down to the ER for the "1 anastomotic leak this year" for the fat pass. This guy was out of control. Apparently the psych screening for him was very weak. This guy was apparently eating KY Jelly POD#1 in the hospital because he thought it was some sort of food. Then he leaks. Why wouldn't he. There's a lot to say about compliance to the program and leak rate. If you try to shove 20 Twinkies, a 20 oz Porterhouse, and a 2 Liter bottle of mountain dew in a 20-30 cc pouch, you're not doing the anastomosis a whole lot of favors.

Sorry to vent. Just joining the crew. Hell, I'm whining as much as the fat passee.