Laparoscopic surgery

[drivesmecraazee]

Im very interested in surgery and Im thinking about making a surgical speciality or fellowship, but laparoscopic surgery doesn't seem very interesting to me compared to the old fashioned open surgery, could anyone tell me which are the specialities or fellowships that still use more open surgery than laparoscopic? I just want to have a clue, an idea so that I can choose wisely.

Thanks a lot.

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[surgeon2b forev]

hi, don't think you may not love lap once you actually learn it.

that said, lots of things are done in a less-than minimally invasive approach. trauma, Coronary artery bypass surgery, if you're interested in urolgoy then neo-bladders andt he like, if you like gyn-onc then most is w/o laproscop. if you do onc in surgery, then of course lots is w/o lap...

transplant too, of course

in all these fields, though, you'll HAVE to perform your fair share of minimally invsaive surgeries 'cuz it's good for patients and is where surgery is going.

 

[Blade28]

You still have a year left until your clinical rotations start - don't eliminate all the other fields (or even minimally invasive surgery) until you've at least seen what they're like firsthand!

Having said that, you'll see more and more laparoscopic surgery in the following:

*General - hernias (inguinal and ventral), gallbladders, appendices, gastric bypass, adhesiolysis, some stomach/small bowel/colon resections, the occasional laparoscopic "look" instead of the traditional exploratory laparotomy, some spleens, antireflux procedures (e.g. Nissen fundoplication)
*Vascular - rarely used, though you will have a lot of endovascular (guidewires/stents) stuff
*Oncology - lots of stomach/small bowel/colon resections, some liver
*Endocrine - adrenals, some minimally invasive parathyroids
*Urology - some bladders and kidneys
*Transplant - donor nephrectomies are being done laparoscopically now
*Trauma - mostly open, but they will occasionally do some of the stuff under General
*Colorectal - lots of colons
*Cardiothoracic - not really "laparoscopic," but lots of thoracoscopic stuff (basically laparoscopy in the chest) including lung resections, sympathectomies, thymomas, esophagectomies
*Pediatric - similar to General above
*Plastics - not much laparoscopy here

 

[drivesmecraazee]

I know I still have a year left and my opinion could actually change...I guess it's just a preliminary that's noit based on experience.

 

[Blade28]

Tough to say you don't like doing something until you've actually done it. I mean, I saw a bunch of laparoscopy when I was a med student (along with neck dissections, AV fistulas, etc.), and thought they were kinda boring - until I actually got to perform them!

 

[drivesmecraazee]

Tough to say you don't like doing something until you've actually done it. I mean, I saw a bunch of laparoscopy when I was a med student (along with neck dissections, AV fistulas, etc.), and thought they were kinda boring - until I actually got to perform them!

Well...maybe that's because they're not so impresive as the things people actally like when you're e med student, you know, when you're a med student you just want to be impressed by everything, probably you got interested in them once you got a new taste of them that can only be gained by experience, a more technical perception...hope it happens to me cause it seem like laparoscopic surgey is being used a lot.

 

[46&2]

Perspectives also change when you have to take care of the patient postoperatively. Laparoscopic Roux-en-Y gastric bypasses, endovascular aortic aneurysm repairs, etc. can go home post-op day 1. Patients with open procedures can linger as you deal with pain meds, respiratory issues, possible wound infection, awaiting return of bowel function, fluid shifts, etc. While it's debatable if there are more or less complications with minimally invasive surgery (MIS), there is little doubt that MIS patients go home sooner, have less blood loss, and have less pain. Really, just spend a week on the ward with a few nights on call with patients who had MIS vs. open procedures, and your beeper will tell you the difference. And then spend a week in clinic, offering patients either MIS or open, and see what the customer prefers. Elective open cholecystectomy is virtually extinct for a reason. Cardiology has already significantly cut into CT's business.

 

[drivesmecraazee]

Perspectives also change when you have to take care of the patient postoperatively. Laparoscopic Roux-en-Y gastric bypasses, endovascular aortic aneurysm repairs, etc. can go home post-op day 1. Patients with open procedures can linger as you deal with pain meds, respiratory issues, possible wound infection, awaiting return of bowel function, fluid shifts, etc. While it's debatable if there are more or less complications with minimally invasive surgery (MIS), there is little doubt that MIS patients go home sooner, have less blood loss, and have less pain. Really, just spend a week on the ward with a few nights on call with patients who had MIS vs. open procedures, and your beeper will tell you the difference. And then spend a week in clinic, offering patients either MIS or open, and see what the customer prefers. Elective open cholecystectomy is virtually extinct for a reason. Cardiology has already significantly cut into CT's business.

What does this means? ...Im sorry, didn't understand it.

 

[Winged Scapula]

[/COLOR]

What does this means? ...Im sorry, didn't understand it.

Uhmmm...stents and other percutaneous procedures reducing the patients requiring open CT surgery is what he surely meant.

 

[FutureMDinTN]

I used to think that I wouldn't like laproscopic surgery either...then I got a job in the OR at a hospital in my town and saw some surgeons to a few lap choles, appys, and even a hemicolectomy, and so now I think it is pretty cool. The best part is the much shorter recovery time and a reduced risk for complications. The only part that I saw that I think I might not like is how tedious it is, especially on longer procedures.

 

[FliteSurgn]

I hated laparoscopic surgery as a medical student. Part of it had to do with the relative incompetence of the attendings and residents that I saw performing the cases. This was over 10 years ago and they were all early in their learning curves. Even so, I could see the writing on the wall and that laparoscopy was going to be huge. I still hated it and vowed to avoid it by going into a fellowship in surg onc or colorectal surgery because those cases would always need to be big open procedures...or so I thought.

The truth of the matter, once I actually got to perform surgery I loved the laparoscope. I was a huge proponent for doing everything laparoscopically. As a junior and senior resident, if I saw an open case on the schedule that I thought I could do through a scope I would call the attending and see if I could talk them into it. By the end of residency, I had performed a number of "firsts" at our institution...gastrojejunostomy for obstructing pancreatic Ca, pancreatic cyst-gastrostomy, and CBD exploration with t-tube insertion (the very first t-tube I ever placed was laparoscopically).

I'm not bragging I just want to demonstrate that from someone who initially hated/dreaded laparoscopy, you can see that opinions not only change, but they can take a complete 180.

Today, laparoscopy makes up a huge portion of my practice...inguinal hernias, ventral hernias, Nissens, splenectomies, adrenalectomies, colectomies, cholecystectomies, gastric bypass/band, appendectomies, etc.

 

[Blade28]

Great story, FliteSurgn! Inspiring! 👍

 

[nina512]

any tips for a 3rd year medical student who will be on a lap/endo team for a surgery rotation?

 

[doc02]

Fashion a wooden splint that will support your arm at a 45 degree angle. Also, cocaine keeps you awake during these cases but you didn't hear that from me.

 

[Winged Scapula]

any tips for a 3rd year medical student who will be on a lap/endo team for a surgery rotation?

Keep the area the surgeon is working in the middle of the screen.

Do not jiggle the camera. As doc02 notes, learn to hold your arm at 45-90 degree angle for hours on end. You are not allowed to have a tremor.

If the CBD is cut, there is a lot of bleeding, etc. do not ask questions at that time.

You may switch hands if you are allowed to drive the camera or other instruments, but do not do so while the surgeon is working.

If you are only allowed to sit in the room and watch, find stool...do not let them catch you drooling in the corner, half-asleep.

If this is your first surgical rotation, usual advice applies.