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"Old school" surgical specialties?

Discussion in 'Surgery and Surgical Subspecialties' started by IcedTea, May 31, 2008.

  1. IcedTea

    IcedTea Nuthin But A G Thang Baby 2+ Year Member

    Apr 18, 2008
    Tha hood
    Minimally Invasive surgery is becoming more common now due to less recuperation time for patients and less complications during surgery.

    I do think minimally invasive surgery is something good, but I prefer those "old school" surgeries where you have to make big incisions and you get to really tinker around inside someone's body using your instruments. For me, the more blood and gore, the better. I am not really interested in using robotics to do surgeries, I rather use good ol fashioned surgical instruments (knives, scissors, etc.) to do surgeries. Like in the old days.

    Which of these specialties would I expect to find the least amount of minimally invasive procedures (i.e. more old school stuff) and the most (more robotics, etc.)?

    Vascular Surgery
    Orthopaedic Surgery
    Cardiothoracic surgery
    General Surgery
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  3. smq123

    smq123 John William Waterhouse Administrator Physician SDN Advisor 10+ Year Member

    Jan 9, 2006
    You wouldn't happen to be related to some 16 year old kid out in Indiana, would you? ( Just wondering.

    You forgot about Transplant. Transplant doesn't do a lot of laparoscopic stuff either - it'll pretty much always require a large incision.
  4. Actually, many minimally-invasive procedures have HIGHER rates of complications due to a more difficult operative field.

    Compare an open appy to a lap appy. The latter has higher chances of bladder perf (from a trocar), enterotomy (from dissection), etc.

    Or compare an open chole versus a lap chole. You can get all kinds of bile duct injuries in the latter.

    Except for lap donor nephrectomies. ;)
  5. Celiac Plexus

    Celiac Plexus Senior Member 10+ Year Member

    Oct 9, 2002
    I don't think that lap appy has a higher complication rate as compared to open appy. Most of the data comparing lap appy and chole with open appy and chole that favors open operations is outdated. Perhaps there is a recent paper on the subject that supports your statement... it's very possible... Let me know.

    However, I stipulate that laparoscopic appy has the advantage of looking around the abdomen and getting a much better view than that gained through a McBurney incision. Also, irrigation is easier and (at least in this general surgery resident's hands) more complete. Port site infections are rare, and patients (and residents) appreciate avoiding a wet to dry dressing regimen, and extra days in the hospital, which add to the cost of treatment.

    As far as a "more difficult operative field", can you expand on that? I have the exact opposite opinion, since in my experience (don't laugh too hard) laparoscopy provides superior exposure. If something is difficult to view, one can always place another port... although that is rarely necessary for a lap appy or chole.

    And as far as comlications from a lap chole... the same complications can occur with an open operation. The data favoring open chole is for the most part outdated. The major study that I have heard favoring open chole was published a decade ago. Then again, I do not possess an encyclopedic knowledge base on the subject so I may be ill-informed. Let me know if there is a more recent study favoring the open approach to cholecystectomy.

    I am one of the 'tweeners who saw mostly open operations in medical school, but have been trained to do mostly laparoscopy as a first option for most elective procedures, and the occasional emergent one. I used to prefer open operations because I felt more comfortable doing them, but once I got the hang of laparoscopy it's actually pretty fun. I can comfortably do a straightforward lap chole in 25-30 minutes, and my lap appy time is 10 minutes to 60 minutes depending on the amount of inflammation. 60 minutes for a lap appy is pretty poor compared to an open time, but I am able to irrigate well and patients have done fine... ususally home in 24 hrs.
  6. Castro Viejo

    Castro Viejo Papa Clot Buster 10+ Year Member

    Jun 3, 1999
    Certainly not Vascular Surgery. More and more peripheral vascular operations are falling victim to the wire and stent. Heck, even when it seems to defy logic... More high volume vascular centers are fixing ruptured AAAs with an endograft rather than the good ole big whack.

    How sad... :(
  7. DrDre311

    DrDre311 Makaveli 2+ Year Member

    Apr 14, 2008
    Castro, I've just had an epiphany and I realize now that you're actually Stephen Colbert. I love your show.
  8. Castro Viejo

    Castro Viejo Papa Clot Buster 10+ Year Member

    Jun 3, 1999
    Word up.
  9. droliver

    droliver Moderator Emeritus 10+ Year Member

    May 1, 2001
    No, laparoscopy still has got slightly higher CBD injury rates compared to historical data, although much less then what was published in the early 1990's.

    Rates in the early 1990's laparoscopic series were being repored as high as 1-3% for CBD injury versus 0.06% to 0.2% for accepted rates with open techniques. Several more contemporary series from around the world put the CBD injury range for laparocopy at 0.1 to 0.6%, which while rare can still be almost 2x as frequent. Complicating things is trying to guess how much CBD injuries are underreported (imporoper ICD-9 reporting or injuries treated non-surgically via ERCP) or unrecognized (ie. small leak or late stricture presentation).
    Last edited: Jun 1, 2008
  10. geekgirl

    geekgirl Senior Member 5+ Year Member

    Feb 6, 2005
    i agree with your sadness. but the defying logic part is not right. we do lots of ruptures endovascularly. and for the most part the patients do great. better than if we opened. sad from the perspective of a person who loves open surgeries (which i do - thoracos f*cking rock). however, the endovascular approach actually is optimal for many of these people who would not otherwise tolerate a huge open whack with minimal medical w/u. give me an incision bigger than my body and i love it, but endovascular rupture repairs are awesome for the patients.

    just my 2c.
  11. Castro Viejo

    Castro Viejo Papa Clot Buster 10+ Year Member

    Jun 3, 1999
    No argument in regards to patient outcome endo vs. open whacks in AAA disease. The literature emerging supports endografts for ruptured aneurysms in high volume centers that happen to stock all the different sizes, but the majority of trainees in Vascular Surgery aren't going to be practicing in such facilities. And it's not just the high volume academic egghead hospitals that are seeing ruptured AAAs.

    I've just never had a great experience in seeing a ruptured AAA fixed successfully open or endo to convince me that one is more superior to the other. I know, I know... The literature says otherwise, but still...

    I can't seem to find my story about the ruptured AAA that was flown the week when all our fellows had gone off to the Moore course at UCLA. This was a patient who had had a previous EVAR, lost to followup with an endoleak, and ruptured the night before being airlifted to our institution. The attending decided the best way to help this guy was to fix the rupture with a bunch of extender cuffs at both ends (covering the hypogastrics on both sides). This took about eight hours or so. I don't remember why exactly. He had trouble occluding proximally with a balloon snaked down from the brachial, I think, so obviously the patient bled quite a bit.

    After the eight hour ordeal, the attending proceeded to pat himself on the back, self-congratulations abound, and as we took the drapes down I decided to doppler the foot. Oh, look, no signals. After a series of four letter words strung together in a way that only a Vascular Surgeon who realizes he now has another three hours ahead of him in the OR can understand, the patient got an ax-bifem.

    Three hours later, great, the ax-bifem worked superbly. Doppler signals could be heard all around New York City. Done, right? Nah...

    Anesthesia said, "Hey, we're having trouble ventiliating the patient. Real trouble."

    One look at the belly, which had become quite a bit more distended than we had remembered 11 hours ago, made us realize that he needed a big whack after all. Oops. :) So he gets a whack to relieve the massive abdominal compartment syndrome which, in the process, produced at least a few loops of lacerated small bowel (for which the General Surgeon on call was CALLED IN to repair) and a packed belly. That was probably another two hours. So, all in all, an endo case that took 13 hours and required a big split down the fascia in the belly hardly seemed satisfying to me.

    If we had cracked his belly from the get go, I'd bet we would've been done in fewer than four or five hours.
  12. CV - that's a terrifying story. Redo EVAR --> ax-bifem --> ex-lap --> silo? Oh lord. :eek:
  13. Castro Viejo

    Castro Viejo Papa Clot Buster 10+ Year Member

    Jun 3, 1999
    Yeah, and I had to pee real bad, though I was surprisingly thirsty.

    I wanted one of those Dunkin' Donuts Coolattas and that was all I could really remember thinking most of the time.

    That would've hit the spot, man...

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