minimally invasive surgery...are you afraid?

[docmemi]

do you feel minimally invasive surgery will take over all surgeries in the future? that is, do you think general surgeons are going down? do most general surgery programs teach laparascopic surgery as part of their program???

i understand that there are 1-2 year fellowships. do you do this after general surgery? is it very competitive? do you make more money as a minimally invasive surgeon?

all i have to say is that minim invasive surgery seems awesome. i cant believe they can do cardiac surgery now, e.g., valvular repair, with laparscopy.

share your thoughts...

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[imtiaz]

it has even spread to smaller rural areas (ie where i go to school) we have 2 surgeons that do thoracab, i haven't had a chance to see any yet but i plan to. it looks pretty awesome.

 

[dry dre]

share your thoughts...

No doubt the future holds more laparoscopic surgery than the past. This being said, it is safe to say that general surgery programs will have to incorporate more and more laparoscopic procedures into their programs. One recently fellowship trained laparcoscopic surgeon with whom I spoke went so far as to say that in the future there will less min inv fellowships as training picks up in the categorical years.

In general I think that current lap specialists are simply unique in a timeframe in surgery where their skills are rare; it's hard to imagine that this will be the norm from now on.

 

[surg4me]

I'm going into gen surg now one of my criteria for interviewing and ranking is whether or not the program offers extensive laparoscopic experience. I feel that a good program should be able to train residents to such a degree so that a fellowship is unnecessary...and many program where I've interviewed seemed to do that. The use of a camera and special instruments to operate are technical skills that should be a part of a core curriculum in gen surg. Many programs will provide the statistics (complicated and simple lap procedures done by graduation) and many residents will actually have logged more procedures than what can be gained from a 1 or 2 year lap fellowship. By the way, laparoscopic fellowships are not board accredited (yet), as is breast surgery. These fellowships basically say that you did additional lap or breast procedures. Plus, if you want the fellowship, they're quite easy to match into, at least at the moment. If you end up at a program that's weak on lap procedures, a fellowship should be highly considered since many general surgery procedures will involve the camera. But if you can avoid it, a program with an extensive lap experience (simple and complicated cases) should receive an extra "point" in my view.

 

[kinetic]

I'm tired of programs all saying, "when so-and-so went to match for a Min. Invasive fellowship, he had more experience than some of the fellows!" They ALL say this. It can get a little irritating. I mean, those must be some sucky fellows.

 

[surg]

I think surg4me hit it on the head though. The laparoscope is just a tool that allows you to do certain operations. It makes some easier and some harder to do. A well trained general surgeon of the future will be able to do virtually any basic lap procedure (e.g. chole, appy, inguinal) and have a reasonable ability to perform moderately difficult procedures (splenectomy, nephrectomy, ventral hernia, nissen fundoplication), and only a few will be able to perform truly difficult procedures proficiently (bariatrics, major liver resection, completely lap bowel surgery which will probably. become only mod. difficult when better instruments are developed).

Some residencies may not truly get you all the way up the curve, but some don't in many high-end general surgery procedures either (Whipple, Complex Liver surgery, etc.) unless you train at a center that has a lot of volume in that.

When I interviewed for (a non-laparoscopic) fellowship, it really drove home to me the variety of experiences my co-applicants had as an early chief. Some hadn't ever scrubbed a whipple, while one of my co-chiefs in my program had done >20 (I'm in between those two). Others felt facile with high end lap. procedures, some hadn't ever done a spleen.

As one of my attendings says "you don't see stapling fellowships around do you?" In the end, the common stuff will get taught everywhere, the uncommon stuff will continue to reside either in high volume centers or in fellowships.

To answer your other questions: fellowship trained lap. surgeons currently are in high demand as groups that don't do this yet as looking to upgrade their offerings, so while I don't have direct evidence of this, I presume that there is a pay differential still at the moment. I expect this to diminish over time as supply catches up with demand. Fellowship matches are moderately to highly competitive depending on the place. Some of these fellowships are almost completely lap. bariatric so if you are looking for someone to teach you to do a lap whipple (don't laugh, it's been described!), only a few places might be able to help you towards that. The fellowship is done after gen. surgery training is complete.

 

[njbmd]

do you feel minimally invasive surgery will take over all surgeries in the future? that is, do you think general surgeons are going down? do most general surgery programs teach laparascopic surgery as part of their program???

i understand that there are 1-2 year fellowships. do you do this after general surgery? is it very competitive? do you make more money as a minimally invasive surgeon?

all i have to say is that minim invasive surgery seems awesome. i cant believe they can do cardiac surgery now, e.g., valvular repair, with laparscopy.

share your thoughts...

Hi there,
Minimally invasive surgery will not 'take over' the future but will be a significant part of any general surgeon's practice. I am totally comfortable doing lap choles and appys but even in the hands of the best laparoscopic surgeons, there is a 10% chance that you are going to have to open. Anatomy, adhesions and inability to perform the procedure safely through the scope are reasons to open and are not failures but part of the process.

I have assisted on about 60 lap gastric bypasses and many hernia repairs, adrenalectomies, VATS, colon resections, splenectomies and nephrectomies. These are senior resident level cases and I will get my share next year when I reach senior resident level. Again, these procedures are very much a part of general surgery training. The laparoscope has enabled the general surgeon to explore and take care of many problems in patients that open incisions would greatly complicate recovery.

A minimally invasive fellowship trained surgeon is in high demand especially if coming from a strong fellowship program. These fellowships are fairly competitive and quite interesting. Working though the scope is great fun with a learning curve that can be steep for certain procedures like Nissens and gastric bypasses.

As you are interviewing for residency, make sure that your program has surgeons who are totally comfortable teaching laparoscopic procedures to residents. You can't wait until fellowship to learn lap choles and appys nor can you expect to go to a weekend course and pick up these procedures.

njbmd 🙂

 

[supercut]

Make sure that you give serious consideration to skills labs as well. I didn't realize how critical it is to have a laparoscopic skills lab until I matched at a program that doesnt' have one. I am at the mercy of the patience of the attendings to learn my laparoscopy. While my skills in open surgery are have been ranked average to above average, I am way behind in laparoscopy.

Typically what happens is I get started on a case, start to struggle, get lost and then the attending looses his/her patience, and grabs the instrument out of my hand and finishes the case. I can hold my own on a lap appy but that's about it.

I don't know why I have so much trouble with it. I know it's important to learn to do well, but I absolutely despise it. Laparoscopic surgery makes my back hurt far worse than open surgery, and I stay constantly frustrated. Lack of a lab prevents me from working to improve my skills.

Bottom line...don't rank any program that doesn't have some sort of inanimate laparoscopic trainer.

 

[Bo Hurley]

Yes, more and more procedures will go minimally invasive. MIDCABG is starting to take over for more and more of the traditional open-sternotomy CABGs. Even more and more congenital heart operations are going minimally invasive. The proposed new field of fetal heart surgery, if it ever gets underway, will likely start as minimally invasive.

 

[jc7721]

two points to really hammer home here, as mentioned previously: 1) you can't and shouldn't have to wait until after residency to have a good exposure to most (obviously not all) lap procedures. I was interviewing last year for residency and one of my criteria was a VERY thorough training in lap during the residency, because it sure as hell aint going away. What did this mean exactly--bariatric, esophageal, VATS, nissen, spleen, GB, adrenal, appy, colon including total colectomy and LAR. Obviously if you want to be a vascular/CT/plastic surgeon your priorities will be different, but for general/peds/GI/onc this 'technique' is going to be more and more routine. 2) skills labs: all those simulators, peg boards, fake abdomens, mirrors, etc have a purpose. Forget the 'lack of randomized, prosepective, double-blinded studies', you need to practice and these labs are one way to do that. This all became so clear to me the other day when I was assisting a fellow (from Man's Greatest Hospital) and an attending during a nissen. Wow. The basics like passing suture, orientation, grasping and dropping, in addition to intracorporeal suturing, needed quite a bit of work. Just an example to bring home the point that you need the volume/breadth of cases and out-of-the-OR practice to really get the most of Lap.

Or forget this and become the maximally invasive surgeon we all want to be!

 

[Celiac Plexus]

The ABS has pretty much conceded to an integrated vascular fellowship similar to the "integrated" plastics pathway. There is also debate within the ABS as to whther or not all of the subspecialties should have "integrated training".

For example, integrated baraiatrics, integrated colorectal, integrated breast.... This is being driven by 2 big forces: increasing patient demand for surgical "specialists", and the desire by many within the greater surgery zeitgeist to trim a couple of years off the training pathway to encourage more women, and "lifestyle" types to enter surgical fields.

I think, with laparoscopy, we will see the integrated pathway open up as well. 3 years of general +2-3 years of laparoscopy. THe reality is that the general surgery residency of 2004 just does not train laparoscopic surgeons. You will get experience doing lap choles, and lap appies, and maybe even some lap nissens, or lap gbp or even some ex-laps... but a few of these procedures does not a hardened laparoscopic specialist make. The one faithful predictor of expertise in surgery is level of experience. You just cannot get high volumes of lap surgeries in general surgery residencies today. And someone is bound to reply that "I did 120 lap gbp surgeries, and 180 lap colectomies..." and yeah there may be some experiences out there like this.... these are the statistical outliers. Currently the RRC requires residents to do only a handful of lap choles to graduate from general surgery residencies. Heck, most programs don't even have a skills lab.

I train at a university program that does a pretty high volume of surgery. Our chiefs for the last couple of years haven't done much more than lap choles, and appies. We recently added a couple of fellowship trained laparoscopists now so we are starting to do lap nissens, lap gbp, and lap colectomies. So maybe the future holds more laparoscopy... but the way things are right now with the RRC's minimal requireements, and the lack of standardized training in general surgery residencies... I think that it will be many years before general surgery residencies start to have significant laparoscopy experiences. Perhaps a more likely scenario is a 5-6 year integrated laparoscopy residency.

 

[docmemi]

i heard that a 6 year cardiothoracic integrated residency was approved, but that no program is willing to implement it. darn it!

 

[droliver]

For example, integrated baraiatrics, integrated colorectal, integrated breast....

I think, with laparoscopy, we will see the integrated pathway open up as well. .

That's an absolutely ridiculous statement. Unlike some of the other specialties that have diverged and evolved from general surgery enough to become their own discipline (CTVS, Vascular, Plastic Surgery)- Breast, Colorectal,Bariatrics, & Laparoscopy-Endoscopy are so involved with core General Surgery that to "spin" them off is illogical. You can't be a General Surgeon without being a laparoscopist and vice versa. Depending upon you exposure during training or desire for superspecialization you may seek additional training, but to think the ABS would seek to marginalize itself in those areas makes no political sense

 

[dr.evil]

dr.oliver's right on this one. Although you can get "superspecialized" in breast, laparoscopy, and colorectal, these areas are some of the core areas of general surgery. These will likely stay as they are with one year fellowships post residency for those who want additional training for whatever reason. I think a lot of that is marketing yourself and being able to focus your practice in a single area (i.e. managing your lifestyle).

All general surgeons can do any breast case, most colorectal cases (although more are tending to push the APR and J-Pouches to the colorectal guys in larger communities), and most laparoscopic cases (again, the more advanced/difficult/untrained areas are being done by the new laparoscopic trained people).

 

[Foxxy Cleopatra]

do you feel minimally invasive surgery will take over all surgeries in the future? that is, do you think general surgeons are going down? do most general surgery programs teach laparascopic surgery as part of their program???

i understand that there are 1-2 year fellowships. do you do this after general surgery? is it very competitive? do you make more money as a minimally invasive surgeon?

all i have to say is that minim invasive surgery seems awesome. i cant believe they can do cardiac surgery now, e.g., valvular repair, with laparscopy.

share your thoughts...

Many, but not all procedures can be done in a less-invasive fashion though it is important to know how to do it open in the case that you either cannot perform it laparoscopically or run into complications.

As the other posters have stated, for laparoscopic surgery, many people do a one year fellowship after residency. Vascular surgery can be a 1-2 year fellowship. Personally, if I decided that I wanted to do general private practice, I'd definitely do a laparoscopic fellowship. I am into my second year of residency and I cannot do much laparoscopically at all as of now. Most programs will give you a fair amount of exposure to the "basics" (lap choles, appys) but I would want a bit more experience after residency should I want to be out there performing lap colons, j-pouches, etc.

On the other hand, there are some things that (at least of now) that I do not see becoming less invasive- take skin grafting for burn patients, rhinoplasty, breast reconstruction, amputations, etc.

 

[Celiac Plexus]

That's an absolutely ridiculous statement. Unlike some of the other specialties that have diverged and evolved from general surgery enough to become their own discipline (CTVS, Vascular, Plastic Surgery)- Breast, Colorectal,Bariatrics, & Laparoscopy-Endoscopy are so involved with core General Surgery that to "spin" them off is illogical. You can't be a General Surgeon without being a laparoscopist and vice versa. Depending upon you exposure during training or desire for superspecialization you may seek additional training, but to think the ABS would seek to marginalize itself in those areas makes no political sense

Wow.

I'd say you made your point!

 

[Misterioso]

Which GS programs are known to provide lots of laparoscopic training to its residents?

 

[Bovie9]

While we are on the subject here- the RRC just changed the minimum requirements regarding minimally invasive surgery (2/1)

http://www.acgme.org/acWebsite/RRC_440/440_minReqLaparoscopy.asp

Basic Laparoscopy (lap chole, lap appy)
Old: 34 cases
New: 60 cases

Advanced Laparoscopy (see below)
Old: 0 cases
New: 25 cases

Endoscopy
Old: 29 cases
New: 85 cases
35 Upper, including PEG
50 colonoscopy

Advanced laparoscopic cases described per RRC:
Gastrostomy and Feeding Jejunoscopy
inguinal and incisional Herniorrhaphy
bariatric Laparoscopy
Anti-reflux Procedure
Enterolysis
Small and Large Bowel
Renal and Adrenal surgery
Donor Nephrectomy
Lap, Splenectomy

 

[AlexRusso]

i heard that a 6 year cardiothoracic integrated residency was approved, but that no program is willing to implement it. darn it!

you might wanna take a look at this:

http://forums.ctsnet.org/ctsnet/thread.jspa?threadID=852&tstart=0