"Big" Surgery

[PostCall]

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What subspecialty of general surgery involves the least amount of fine vascular anastamosis and minimally invasive (laparoscopic)? Vascular and Cardiac are out for obvious reasons. What about hepatobiliary or colorectal or pure thoracic (noncardiac) surgery? Basically what are the big open whack specialties.

 

[SLUser11]

What subspecialty of general surgery involves the least amount of fine vascular anastamosis and minimally invasive (laparoscopic)? Vascular and Cardiac are out for obvious reasons. What about hepatobiliary or colorectal or pure thoracic (noncardiac) surgery? Basically what are the big open whack specialties.

Hepatobiliary. Trauma (but not that often).

Colorectal has a few "big whacks," but there's a lot of laparoscopy. Transplant can have big incisions, but there are plenty of vascular anastomoses.

Purely thoracic surgery may have some big incisions, but there's more and more thoracoscopic surgery being performed, and most training programs will be at least 50% cardiac, which has lots of anastomoses.....my chief resident just told me there are 17 purely thoracic programs in the nation that may be worth a look.

 

[SouthernSurgeon]

HPB is becoming more and more minimally invasive (lap liver resections, the advent of robotics, etc)

 

[ESU_MD]

.....my chief resident just told me there are 17 purely thoracic programs in the nation that may be worth a look.

and the best one is right there in Houston.

 

[PostCall]

HPB is becoming more and more minimally invasive (lap liver resections, the advent of robotics, etc)

Darn. Is there any subspecialty that in the future will still be done primarily open?

 

[DrNick Riviera]

Transplant.

 

[SLUser11]

Darn. Is there any subspecialty that in the future will still be done primarily open?

Mission surgery. Many areas of Africa are just being introduced to laparoscopy.

Transplant surgery maybe on the recipient end, but I would bet that most live donor procedures will be done laparoscopically or robotically in the future. I personally found retrievals on brain-dead donors to be some of the funnest cases of residency.

Breast surgery...technically, but the incisions are getting tiny. (On a side note, WS, do you ever use the dilators to bluntly develop a plane during skin and nipple-sparing mastectomies? I saw pics in a JACS article but I've never done it.)

Anyway, we all love the big open procedures, but do you really dislike laparoscopy that much?

 

[PostCall]

Anyway, we all love the big open procedures, but do you really dislike laparoscopy that much?

I don't find laparoscopy as satisfying as open procedures. It feels more like playing a video game than operating. I like dissecting, cutting, tying, suturing with my own hands rather than using lap instruments to do it on a tv screen.

 

[PostCall]

.....my chief resident just told me there are 17 purely thoracic programs in the nation that may be worth a look.

I thought all CT fellowships were combined cardiac and thoracic, with some fellowships offering more experience in the thoracic part (the thoracic "track" programs). The only pure thoracic fellowships I've heard of are ones that can be done AFTER doing a standard CT fellowship. Are there pure thoracic (no cardiac) fellowships that can be done straight after of a general surgery residency?

 

[OtoHNS]

If you were a pure head and neck oncologic surgeon, most of those procedures are still done as big open whacks. There is plenty of sewing in holes though, and there would be lots of laryngoscopies/esophagoscopies for biopsy purposes. Even H+N is moving in the direction of minimally invasive though with the advent of transoral robotic resections of pharyngeal and laryngeal lesions. And people have been doing endoscopic laser resections for certain lesions for years as well.

Also, you would need to do an ENT residency first which has tons of endoscopic procedures.

Pretty much every specialty is moving in the direction of less invasive/less intensive procedures whenever possible. I don't think you can avoid it entirely no matter what you end up doing.

 

[HonestTruth]

interesting

 

[Winged Scapula]

(On a side note, WS, do you ever use the dilators to bluntly develop a plane during skin and nipple-sparing mastectomies? I saw pics in a JACS article but I've never done it.)

Sometimes. Don't really need to use the dilators, I find my fingers work just as well.

Sometimes I use Gorney scissors.

Sometimes Bovie or Peak.

Really just depends on the tissues, how much time I have and my mood.

 

[droliver]

try this sometime. Inject the breast with a 18g spinal needle and 60 cc syringe with 500-700cc from a mix of 1L NS + 1 amp 1:100,000 epi. Let that stand for about 10-15 mins. Take 3 or 4 mm liposuction cannulas and tunnel (not hooked up to suction) the hell of the skin flaps using your off hand for guidance. Make your mastectomy incision for your nipple sparing approach and you will see that you have essentially degloved the parenchyma at the sub-cutaneous/parenchyma plane with just a handful of retained dermal ligaments to divide with scissors. The breast will then literally peel of the fascia with light cautery on the pectoralis side and you can deliver it out en bloc having had to use very minimal cautery. This is a really slick way to do this and minimize collateral damage to the flaps prior to immeadiate reconstruction.

Try this on a small prophylactic mastectomy sometime as that's the easiest way to learn this.

 

[Winged Scapula]

Steph,

try this sometime. Inject the breast with a 18g spinal needle and 60 cc syringe with 500-700cc from a mix of 1L NS + 1 amp 1:100,000 epi. Let that stand for about 10-15 mins. Take 3 or 4 mm liposuction cannulas and tunnel (not hooked up to suction) the hell of the skin flaps using your off hand for guidance. Make your mastectomy incision for your nipple sparing approach and you will see that you have essentially degloved the parenchyma at the sub-cutaneous/parenchyma plane with just a handful of retained dermal ligaments to divide with scissors. The breast will then literally peel of the fascia with light cautery on the pectoralis side and you can deliver it out en bloc having had to use very minimal cautery. This is a really slick way to do this and minimize collateral damage to the flaps prior to immeadiate reconstruction.

Try this on a small prophylactic mastectomy sometime as that's the easiest way to learn this.

Rob,

you talking to me (not sure who Steph is)?

That is basically how I do it, except I don't use the lipo cannula to develop the plane, just do it bluntly with my hands. Its worth a try except that most of the hospitals I go to (except Scottsdale, of course) don't do much cosmetics, so I'm not even sure they would have the lipo cannuale. I like trying new stuff when I have time.

Even if the above wasn't meant for me, thanks! 😉