I disagree. There are alot of other ways to manipulate the gallbladder and enhance visibility without moving your left hand. Being good with the 30 degree camera, for one, is key to having good visibility. Knowing how to manipulate the hook in an effective, safe manner seems equally as important.
As for the retraction on the infundibulum, you can only pull it in so many directions. And when I do the case, the fundus remains static during the critical portion of the case, retracted over the dome of the liver. I've done the surgery both ways multiple times (left hand on the camera, and left hand manipulating the gallbladder), and I honestly don't see a big difference in the level of difficulty.
I guess what I'm saying is that I don't think knowing how to retract is the key to "advanced laparoscopy." The only exception is possibly when the attending prefers the "dome down" approach. I do find the retraction somewhat more difficult in that case.
Don't get me wrong: I am not an expert at lap choles, and I am most certainly not an expert of advanced laparoscopy. If you read my first post in this thread, you can see that I also didn't come here to brag about my experience. However, I've done a lot of them, both as a first assistant, and as a junior surgeon. I've been on both sides of the table, had all the different instruments in my hand, and seen multiple different approaches to yanking out gallbags.
That is because I am at a community program, and no gallbladder is safe in private practice, especially the healthy ones. And I can't help but take a little offense when you insinuate that any intern doing the case is either some ridiculous phenom, or is unknowingly being piggy-backed through the entire case by the attending.
Maybe being good at gallbladders makes you a PGY-2 phenom in New York, but it is par for the course in Wichita. Not because we're better surgeons, but because our caseload is very different than yours. Your experience is obviously different, but please don't assume that the way your institution does things is the only way.
Operating is about retracting to help you discern the correct tissue planes and to allow a proper dissection. Without good retraction, you can't possibly operate safely or effectively. That's really my point and it's one that usually is lost on the juniors who think operating is all about who gets command of the electrocautery device.
So when I was curious as to how interns and, in your case, PGY 2s across the country were doing lap choles, I was pleased to hear that you've done them with a grasper in your left hand (presumably) in the R subcostal, midclavicular port and the electrocautery in your right hand through the sub-xiphoid port. It's great training for the more advanced stuff when you need both your hands to work in concert with the assistant, and the muscle memory involved in how hard to pull on stuff (with your left hand) to get the planes exposed will be the key to getting the operation done safely and without too many risks.
What I was a little surprised with was your belief that it doesn't take much more skill to operate with both hands as opposed to having your assistant (in most cases I'll assume an attending) hold both graspers and you've got a camera in your left hand. It may not for you, but when I transitioned from my internship to my more senior levels of residency my colleagues and I found it hard to operate with both hands laparoscopically. It takes some getting used to become facile with tension on the left hand and exposing the appropriate tissue planes. But that's just me.
There may be more than a few ways to skin a cat, true, but there are only a few ways that are considered safe and standard of practice. I'm in my Chief Resident year at a
community program as well and, I agree, no gall bladder is safe in the community setting. With over 250 lap choles logged (as surgeon junior and TA) I've been instructed on a variety of ways to take it out, but only a few are accepted and considered standard.
Hell, I've seen cases where while doing my regular thing the attending blurted, "What the f___ is this nonsense?" asked for a stone grabbing forceps and shoved it into a plane between the liver bed and the gall bladder, twisted it around a few times, and basically ripped it out of the liver. He got the job done, sure, but that's damn dangerous. Or the other attending who decided dissecting in Calot's triangle was way too dangerous and the risk of injuring the CBD too great, so he
routinely amputated the gall bladder at the infundibulum and tied off the remainder of Hartman's pouch leaving a little gall bladder stump. Now that's just criminal.
I apologize if you took such great offense to my earlier comments. But in all seriousness you should be a little more open to suggestions from some of us who have "been there, done that" a few hundred times more.
Good luck.
Any interns out there feel me on this?
