Consulting other services for "basic" skills

[doc05]

I think I learned to put the LLQ port much lower than you guys which is great for hiding under a bikini but makes the dissection less easy than using the umbi and suprapubic ports for me at least. But different stuff works for different folks. We have one attending who taught us "south African style" with a right sided port instead of left and I hated it with a passion but he does a nice quick appy with it.

"hiding under a bikini"?? Where are you practicing?

---

Members don't see this ad.

 

[Smurfette]

I use a 5/30 scope the whole case (no switching...why bother opening two?) but staple through the umbilical port after dissecting via the 5 mm ports (mostly because I'm short and don't like to reach around someone holding a camera the entire case). I'm much quicker closing an umbilical port than using a Carter-Thomasson in the LLQ. And I'm generally faster than some of my colleagues at appys.

I never understood right sided trocars for an appy, but then again, as long as you can get it done, it doesn't matter. The colorectal surgeons where I did residency would put lap appys in stirrups and stand between the legs to do the cases. Seemed ridiculously more difficult and time consuming that way.

 

[vhawk]

Ok so let's talk lap chole. My standard for that is 5 at umbo, 12 at subxiphoid and then 2 more 5s right subcostal. But I've done it numerous ways, such as all ports midline, 5 in LUQ instead of at umbo, 3 ports, and have also done it in lithotomy.

 

[dpmd]

"hiding under a bikini"?? Where are you practicing?

California

 

[dpmd]

Ok so let's talk lap chole. My standard for that is 5 at umbo, 12 at subxiphoid and then 2 more 5s right subcostal. But I've done it numerous ways, such as all ports midline, 5 in LUQ instead of at umbo, 3 ports, and have also done it in lithotomy.

Our 5 scopes suck so bad I gave up on using them for chole. So 11mm at umbi and epigastric with 2 5mm ports roughly aligned with what my open incision would be. I could do a 5 at the epigastric but I like to pull my gb through there. One of my colleagues does it with 3 ports only which I don't get how it doesn't make it harder. Then again he does appys with only 2 ports (he sticks a grasper alongside the camera). He is slower than me at that for sure (I am informally judged as fastest though there is another colleague who does only open appy who is roughly the same speed as me)

 

[rigid]

I just use a 5/30 for the whole case, put it through the umbo port, and do the dissection through suprapubic and LLQ. That way the stapler is the exact same angle as the Maryland. No switching or anything.

Honestly I rarely use anything other than the 5/30. It's wasteful to open more than one scope and in case I need to move around the 5/30 fits anywhere. The image quality is definitely a bit worse but almost never enough that it is a dealbreaker. Only time I open two scopes is when using optical trochar since I cannot stand using a 0 degree for anything

You could conserve even more by not using a stapler though

 

[Dr.LeoSpaceman]

Ha, I was just about to ask this myself. The majority of our attendings do it LUQ optical, 11mm umbo and two RUQ 5mm. While this works most of the time, the angle for dissection for the LUQ can be off and if you have to use a 10mm clip applier the angle from the umbo is terrible.

Some do a cut down at the umbo, which let's you put the 5mm subxiphoid which is better for dissection, but still leaves the issue of the 10mm clip applier.

We do have one that does the subxiphoid 11mm, which I've found I prefer the most. I also like the idea of avoiding the 11mm at the umbo for hernia reasons.

Eventually I think this will be my chosen method. However, still not sure on getting in. I prefer the optical separator myself, but that would leave me with a 5th LUQ port. Ive never been taught the veress at the umbo.

 

[vhawk]

We very routinely did a veress at the umbo, like I've done it probably 500 times or something, then in fellowship they were MORTIFIED that I would ever do such a thing. The theoretical objection makes some sense, namely that the big fear of veress entry is deeper vascular injury so doing it at umbo directly over aorta and cava seems dumb. So in fellowship we did veress in LUQ only, which I agree took some getting used to as the right hand for dissection for choles, but you get used to it. I think having the 11 subxiphoid for extraction is ideal because it should be very low hernia risk

 

[dpmd]

Ha, I was just about to ask this myself. The majority of our attendings do it LUQ optical, 11mm umbo and two RUQ 5mm. While this works most of the time, the angle for dissection for the LUQ can be off and if you have to use a 10mm clip applier the angle from the umbo is terrible.

Some do a cut down at the umbo, which let's you put the 5mm subxiphoid which is better for dissection, but still leaves the issue of the 10mm clip applier.

We do have one that does the subxiphoid 11mm, which I've found I prefer the most. I also like the idea of avoiding the 11mm at the umbo for hernia reasons.

Eventually I think this will be my chosen method. However, still not sure on getting in. I prefer the optical separator myself, but that would leave me with a 5th LUQ port. Ive never been taught the veress at the umbo.

I do veress at the umbi all the time. If you stabilize your hand and don't try to hub the damn thing I would say your major vascular injury rate should be very low. I do it even in nonvirgin abdomens which is admittedly risky in terms of adhesions but same principle of slow careful placement applies. If it is just omentum you either end up below it and having to figure out how to get above or you get lucky and end up in a clear patch. If it is bowel no bueno. I always look at that port from a different one to reduce the chance I will miss an injury to the bowel. My colleague who does all Hassan entry at umbi sometimes gets in and sees omentum plastered and doesn't even bother putting a scope and some gas in to see if he can get around it. I am sure he converts to open cases that I might have succeeded at laparoscopically. It is all about trade-offs. I do a LUQ entry (veress also) on occasion but dislike the trade-off on dissection most of the time so I pretty much just do my laparoscopic vp shunts or very pregnant appys that way.

 

[balaguru]

I've never really liked the Veress but use it for mostly lap gastrostomy tube placements where I am placing a 5mm trocar at the umbilicus. I apply anterior traction on the abdominal wall with a penetrating towel clip through the umbilical stalk to keep the needle as far away from vessels as possible.

I generally always do a cut down at the umbilicus as follows: dissect down stalk with metz as I walk down the stalk with penetrating towel clips until I expose fascia, incise fascia 1cm with bovie on cut, place figure of eight stitch and finally use non-Hassan 12mm trocar with 5/30 scope inside to guide trocar under visualization through preperitoneal fat and peritoneum while applying anterior traction using towel clip. The stitch can seal around the trocar if needed (which almost never is) and is used to close the defect when done. Feels both safe and fast in my hands with minimal need for help from an assistant. I never use a 10mm scope.

For appys I use a 12mm supraumbilically, 5mm lateral to the rectus (avoids epigastric) and 5mm suprapubic. For gallbladders, 12mm supraumb, 5mm subxiphoid, 5mm RUQ and 5mm RLQ in a skiving trajectory (usually has to be guided around the epigastric). The last trocar is used to grasp the gallbladder and the drapes are used to pin it in place so the scrub tech can drive the 5/30 camera with both hands. I almost never have an assist for my cases. Sometimes a second scrub tech will help out if available. Super obese, prior surgeries and pregnancy are handled differently.

Boy, this is off topic but it is always fun to compare notes.

 

[armybound]

Oh man I wish it were rare for me to injure an epigastric! If it happens to you just call me I know at least 5 ways to fix it, and 3 of them even work (usually)

I've put a half dozen ports through the epigastric, I've put drains through it, I've put the suture passer through it, I've put an 11 blade through it. I've injured it open, I've injured it lap, I've injured it robotic. I've clipped it, I've sutured it, I've coiled it (that one was less fun) I've held pressure on it, I've watched it turn into a baseball sized hematoma and eventually tamponade. I've transfused prbcs for it I've transfused ffp for it I've given vitamin k for it.

You'd think eventually I'd just learn to avoid it

That's funny, an attending recently chewed me out and told me it was "careless" and he'd "never seen" someone put a drain through an epigastric before.

 

[armybound]

"We have a consult for you, it is a bleeding tunneled dialysis catheter."
"Who put the catheter in?"
"Interventional radiology
"Have you let them know that their patient is bleeding?"
"But the patient is bleeding, so we called vascular surgery."

After 10 or so of these identical conversations a junior resident got pissed and reported the phenomenon to the state medical board for patient abandonment. It didn't end well for really anyone, but it was a great, "you did what?!?!" at a morning report.

Got a consult not too long ago for an inguinal hernia.

"Well it's involving the scrotum, so I thought you should see the patient"

 

[Jolie South]

That's funny, an attending recently chewed me out and told me it was "careless" and he'd "never seen" someone put a drain through an epigastric before.

I’ve never put a drain through one but I have mowed through them with hot scissors and tacks before.

 

[armybound]

I’ve never put a drain through one but I have mowed through them with hot scissors and tacks before.

I can't remember the last chief resident who didn't present one at M&M at some point in their career. Either with a drain or a robot port.

 

[Jolie South]

I can't remember the last chief resident who didn't present one at M&M at some point in their career. Either with a drain or a robot port.

I tend to be more careful with ports and drains but sometimes I get excited with the hot scissors and the tacker. Hahahahaha

 

[vhawk]

The drain one was at the end of a really rough 8 hour whipple, popped the tonsil through, pulled up the drain, minimal bleeding no real issue. Pulled the drain on like day 4, still no issue. Got a scan for unrelated reason on like day 10 and they commented on a large pseudoaneurysm of the epigastric. We ended up having them coil it which j still think was entirely unnecessary.

 

[Socrates25]

I'm not a surgeon, but in gen peds residency we were expected to do all the NG tube placements as well as transpyloric tubes. In my 3 years I probably did around 100 NGTs and maybe 40 transpylorics. Obviously the procedure is different for kids vs adults but it's considered a pretty easy procedure with a very low complication rate.

That being said, there were a couple of occasions where things turned out badly in our program, but it was never during the placement of the tube. It was failure to check an x-ray before using the tube for feedings or a patient who later grabbed the tube, partially pulled it out, and then somehow got it reinserted into the trachea. The nurses are supposed to recheck depth measurements on the tube every time prior to running fluids or feeds and for whatever reason the nurse didn't recognize that the depth marker was different than the prior reading.

As to the larger question, the right answer is to always do what is best for the patient. That means you get somebody more experienced to help if you are unsure of what you are doing. The service being consulted to do a procedure they think is beneath them needs to bite their tongue until they can organize a meeting between the departments to get the training sorted out and prevent repeat occurrences in the future.

Subspecialty services tend to get snarky when asked to do "easy" stuff that they figure the consulting service should be able to do, but they need to recognize that patient benefit should triumph over turf wars.