Open Surgery

[toxic-megacolon]

So this is sad, but as a PGY-4, I finally did my first open chole. This was with an attending who is notorious for being a very poor first assistant (though probably one of our biggest assets because he lets us do the case). To my surprise, I figured it out pretty quickly. It was a nasty cholecystitis gallbladder, but doing it open was significantly easier than lap. Now this seems like common sense, but made me think about all the older, crustier attendings stating that with laparoscopy, residents today aren't going to be comfortable with open cases. I would tend to argue at for many cases, if you are comfortable with the laparascopic version, you'll be able to figure out the open version pretty quickly if you have a basic general surgery skill set. Its sort of like someone saying, if you drive a manual transmission car too much, you'll forget how to drive an automatic--which is obviously ridiculous.

People have proposed "Open Surgery" fellowships, but I can't see this being of as much value as some people think.

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[JackADeli]

So this is sad, but as a PGY-4, I finally did my first open chole...

People have proposed "Open Surgery" fellowships, but...

Nobody has the "right answer" to this dilemma. Just as GBs, there are less open appendectomies. I got all my open appys on the pediatric surgery service.... but those are rapidly converting to lap. The ABS/ACS is very concerned about this reality. Some have suggested the "emergency surgery" type curriculum to which the open GBs and such might also end. There is not any real good answer.

 

[Encephalectomy]

maybe a rotation in a third world country? I spent a few weeks shadowing a surgeon at a public hospital in mexico and there was definitely no laparoscopic equipment, and in one month you would definitely see plenty of the bread and butter appys and galbladders.

 

[toxic-megacolon]

maybe a rotation in a third world country? I spent a few weeks shadowing a surgeon at a public hospital in mexico and there was definitely no laparoscopic equipment, and in one month you would definitely see plenty of the bread and butter appys and galbladders.

My whole point is that experience in open surgery doesn't seem to be as important as some people are saying. I think mastering the laparascopic version puts you in a good position to figure out the open version. Open appys and choles are not hard if you can do the lap version well.

 

[Encephalectomy]

i guess my post was more in response to JAD.

Good to know that the laparoscopic training sets you up to learn the open procedures quickly, but a month in a 3rd world setting would probably be enough to get you truly comfortable with the open operations for bread and butter type things, definitely sounds better than an 'open surgery' fellowship. You've been in residency for over 3 years and this is your first open GB. If you never had another one would you be comfortable doing it if you needed to?

 

[SLUser11]

My whole point is that experience in open surgery doesn't seem to be as important as some people are saying. I think mastering the laparascopic version puts you in a good position to figure out the open version. Open appys and choles are not hard if you can do the lap version well.

While the actual dissection may be easy to understand, I feel that correct exposure in open choles is difficult, and this is where experience is important.

I've done plenty of open choles, but not many conversions from lap to open chole (maybe 6 in 4 years, and we do a buttload of choles). I've done open cases for GB cancer, and we take the gallbladder with most big liver resections. For me, I feel the hardest part in practice will be getting adequate exposure to the GB without my attending helping me with the retractors.

Also, I think that our increasing laparoscopic skills have made us too aggressive with lap choles. At my institution, we are taking gallbags out with cholecystitis well beyond the 72 hour window, and they can be a gigantic mess. For me, if I didn't get the GB out in the first 3-4 days after the cholecystitis started, then I'm cooling the GB off and coming back another day to cut it out.

 

[tussy]

A tough GB is tough regardless of how you do it. I sometimes persist laparoscopically because i know it will be just as challenging open (as long as i'm being safe there is no harm chipping away thru the laparoscope).

Normal GB are easy to remove open (you'll do plenty on hepatobiliary surgery) but the bad cholecystitis are a challenge. I think they were a challenge in the days before laparoscopy just as much as today and i bet residents struggled to get enough "hard" gallbladders in just as today.

If anything, with the rates of obesity and diabetes skyrocketing, the number of difficult choles is increasing if anything. As long as residents are doing enough gen surg call there should be no problem getting enough cases in.

 

[glade]

You shouldn't feel such angst about not having done open cholecystectomies. It's been a complaint for years that people have lost this skill and the reason is because the laparoscopic approach, even for "really bad" gallbladders, is so effective. Is it bad that we've lost that skill? Yes and no. The argument is that you really should be able to deal with anything you run into, so if you find that you need to convert to open you should be able to. On the other hand, the rate of conversion is pretty low. And I'm sure we've all joked about laparoscopic guys who are literally incapable of performing open operations because they've forgotten how. (The more famed a laparoscopic surgeon, the worse they are when it comes to open because they're never opening. They really do suck a lot at open operations. You can't stay competent at something you don't do for years.)

 

[opr8n]

So this is sad, but as a PGY-4, I finally did my first open chole. k.

wow , seriously?

Ive done about 20 open choles

Im not sure what that says about my training, good or bad

 

[JackADeli]

...I think mastering the laparascopic version puts you in a good position to figure out the open version. Open appys and choles are not hard if you can do the lap version well.

While the actual dissection may be easy to understand, I feel that correct exposure in open choles is difficult, and this is where experience is important...

I appreciate what ToxM is saying.... but must disagree. The question is how much do you really need to know? If you don't need to know these procedures that well, it is not the same thing as simply presuming the procedures you are doing make you good at these that you don't do. It is easy to get spoiled by high def lap camera views. Open appies with a purulent abd has very, very poor visibility. There are numerous complications that can occur. Similarly, looking down on the top of the GB is very limited view. again, plenty of complications. Once you are done with the actual procedure, you need to close the abd wall. I have seen numerous poor closures with a basic lack of understanding of the abd wall muscles and tissue layers. If you spend most of your career making stab incisions and twisting a port through the abd wall, you are likely to have less familiarity with its components. Laparoscopy, robotics, NOTES do not ~expand your ability to do open procedures. Simple surgical principle is that if you do not regularly do a procedure, you will not be good at it....period.

Just to add further to the "open fellowship" dilemma.... ABS/ACS is concerned. But, will the medicine be worse then the disease? We are seeing a significant drop in open experience. So, what does it do for GSurgery resident experience if you now have a "fellow" in your institution specifically there to do the open procedures?

...Also, I think that our increasing laparoscopic skills have made us too aggressive with lap choles...

I must agree. I find it sad to see a frail and sick patient on the table for 5 hrs because the surgeon wouldn't (?couldn't) open to remove the GB.....

 

[glade]

wow , seriously?

Ive done about 20 open choles

Im not sure what that says about my training, good or bad

I'd say that's quite unusual in this era. I've only done one ever. If you've converted from lap 20 times during training, I'd say that says that someone either has really bad luck with patients or else, frankly, they suck. But it's great for you, I suppose.

 

[glade]

By the way, since we're also mentioning open appendectomies, I'll throw in that I enjoy doing appendectomies open. In training, although I also found it was the pediatric surgeons who tended more towards open operations, I also had a few general surgery attendings who did them open routinely. There's really no difference in incision size, for all practical purposes, and it's easy. (For fatso patients, though, lap is the way to go.)

I'm also into open inguinal hernias. I knew one guy, who I still think was the best I've ever met at hernia repair, whose technique was unbelievable. His incision was incredibly small and his dissection was impeccable. I've always strived (and failed) at emulating him. But as a result, I'm firmly in the camp of open inguinal hernias. I find that most people who are strong advocates of lap in that instance just blow at open.

 

[Smurfette]

I also converted about 20 choles to open during residency. You have to keep in mind the patient populations that different residency programs have. My experience was due to the county hospital experience, with significantly delayed presentations on patients with minimal access to health care, who either 1. were very sick and needed their GB out asap (including diabetics, pts who were getting septic, etc.), 2. not horrendously sick but failed to improve on abx therapy and couldn't tolerate p.o. or 3. clearly told us they had only been having pain for x number of days when, upon looking at their gallbladder, appeared to have (acute on) chronic cholecystitis for a significantly longer period of time that would have been managed conservatively had we known (usually these people would admit to 5-7 days of pain after the fact).

It was good experience, since I have seen such horrible GB pathology that I can handle a difficult lap chole reasonably comfortably (it was rare at the county hospital to see a 'normal' cholelithiasis chole), but also know to not waste time before converting to open. I agree that converting to open is preferable to screwing around laparoscopically for an hour or more just to delay the inevitable. The ones that are bad laparoscopically are still ugly open cases...JAD is right in that visualizing structures in a open chole is quite different than laparoscopic, and it can be challenging from this angle as well.

 

[ESU_MD]

My favorite open chole story:
was on call one night and got a routine call from the er for symptomatic gallstones. get out of bed, see the pt and setup the or.
in a strange turn of events, the lady REFUSED lap chole and would only consent to open chole.
Luckily, my staff was cool with it and I got to do an open chole on a relatively normal organ.

 

[droliver]

The classic open technique is a little different, you go from "dome down" to mobilize and expose first instead of heading for the duct area like you do with most laparoscopic techniques.

There are some laparoscopic guys who have advocated dome down techniques but it's never really caught on. The advantage of this approach is clearer look at the CBD so those rare bile duct anatomic varients pose less risk to misidentification and transection.

As noted, if you've never done a lot of open surgery the biggest thing is you tend to flail around struggling with exposure. Something as simple as packing the bowel out of the way goes a long way to making an open cholecystectomy pretty easy. I always tried to teach my junior residents to just watch the exposure techniques of some of the surgeons you think are good rather then getting so excited in sewing something that you miss the important elements of the case. Same thing goes double for LE vascular surgery -> Early in your career, watch how that get to the vessels rather then worrying about the anastamosis

 

[glade]

You have to keep in mind the patient populations that different residency programs have.

Absolutely, that's why I said it's possible that it's just bad luck with patients. Or good luck, depends on how you look at it.

 

[JackADeli]

...As noted, if you've never done a lot of open surgery the biggest thing is you tend to flail around struggling with exposure. Something as simple as packing the bowel out of the way goes a long way to making an open cholecystectomy pretty easy. I always tried to teach my junior residents to just watch the exposure techniques of some of the surgeons you think are good rather then getting so excited in sewing something that you miss the important elements of the case. Same thing goes double for LE vascular surgery -> Early in your career, watch how that get to the vessels rather then worrying about the anastamosis

QFT. Great to see DrOliver around these parts....

Another general principle in surgery..... if you can't see it, it is very unlikely you will be able to operate on it well. That is why MIS folks can sometimes get into trouble. They can be so used to wide and magnified High-Def views. It just not so easy when your visibility is taken back about two decades

 

[SLUser11]

I also converted about 20 choles to open during residency. You have to keep in mind the patient populations that different residency programs have. My experience was due to the county hospital experience, with significantly delayed presentations on patients with minimal access to health care, who either 1. were very sick and needed their GB out asap (including diabetics, pts who were getting septic, etc.), 2. not horrendously sick but failed to improve on abx therapy and couldn't tolerate p.o. or 3. clearly told us they had only been having pain for x number of days when, upon looking at their gallbladder, appeared to have (acute on) chronic cholecystitis for a significantly longer period of time that would have been managed conservatively had we known (usually these people would admit to 5-7 days of pain after the fact).

My only problem with this is that patients who present with delayed pathology can usually be treated non-operatively, and then brought back electively for a much easier and safer lap chole down the road.

As for being "very sick and needing their gallbladder out ASAP," I'm not convinced that there are many patients that fit that category. Most people who are that sick need a cholecystostomy tube, not a big morbid operation.


This is a little more controversial, but I wouldn't be surprised if down the road, there will be a push for Dx laps with drain placement as a preferred treatment over conversion to open chole.

There will, of course, always be the patients with bad adhesions/scarring that have gallbags not amenable to laparoscopic resection. At least we can still do their surgeries open.

 

[Buzz Me]

I've learned that when you're struggling during a case, often it's because of poor exposure. When you're in a complex case and merely first-assisting the attending, remember to really watch him/her and see how they set up their exposure, and how the dissect and expose tissues for you to ligate/Bovie. Otherwise, the first time you're trying to take a junior through a case, you'll realize how much help that attending was and how little you remembered.

As for the lap vs. open chole issue, I've done around 40 lap choles, with 4 of them being converted to open. And I've done another 4 open choles that were planned (during big abdominal whacks).

We also did the dome-down approach once, laparoscopically. That got messy.

 

[JackADeli]

...As for being "very sick and needing their gallbladder out ASAP," I'm not convinced that there are many patients that fit that category. Most people who are that sick need a cholecystostomy tube, not a big morbid operation...

I can not comment/second guess too much on the post being referenced. There is some controversy. However, I will say that in general a really bad GB with septic patient is better served with a drain and antibiotics as you note. Sometimes, depending on other finesse points in a given scenario, ERCP as well. This topic is one that I have heard being a favorite of the boards. They want to be sure you are reasonably safe and know when NOT to operate.

A similar scenario is a bad appy with collection.... again, often an IR guided drain and antibiotics. The scenario at the boards will often then go to how long do you leave the drain. What approach do you use for the interval appy (i.e. lap vs open and what open incision/s). They may spice it up with some additional issues during the time between drain and eventual OR. I had them ask about stool coming out of the drain after two weeks.

 

[opr8n]

I'd say that's quite unusual in this era. I've only done one ever. If you've converted from lap 20 times during training, I'd say that says that someone either has really bad luck with patients or else, frankly, they suck. But it's great for you, I suppose.

only converted from lap about 4-5 times, the other 15 were planned open choles (5) and choles at times during other big open abd cases (10)

 

[tussy]

I had to do an open chole my very first night on call as a staff. Old lady with acute on chronic cholecystitis that had an undiagnosied choleduodenal fistula and of course, when i started taking the adhesions down off the gallbladder laparoscopically and ended up "discovering" the fistula. Had to open, drain, kocherize duodenum and repair hole with a jejunal patch and then get the gallbag out! I was almost ready to quit at that point. Have only done 2 more open as staff in the year since (about about 50 lap).

 

[Guile]

People have proposed "Open Surgery" fellowships, but I can't see this being of as much value as some people think.

Just to add further to the "open fellowship" dilemma.... ABS/ACS is concerned. But, will the medicine be worse then the disease? We are seeing a significant drop in open experience. So, what does it do for GSurgery resident experience if you now have a "fellow" in your institution specifically there to do the open procedures? I must agree. I find it sad to see a frail and sick patient on the table for 5 hrs because the surgeon wouldn't (?couldn't) open to remove the GB.....

The Cleveland Clinic already has an open fellowship, so I've heard.

 

[Skialta]

"So this is sad, but as a PGY-4, I finally did my first open chole."

A little off the subject but I guess you don't rotate at a VA hospital?🙂

Skialta

 

[treehorsio]

I agree with a previous post. My program is heavy in HPB...we do around 30 Whipples during our time, and you definitely see the exposure. Plus, most are done thru subcostal incisions, so it's a similar technique.

I don't think that we will ever "forget" how to do open surgery as residents. There will always be open cases, no matter what. We are a big lap institution but only do 40% of our colorectal cases lap. Not to mention trauma ex laps, redos, conversions, etc. For the record, I've done 65 lap choles and 6 opens (including 5 conversions). And...I've not yet had to convert at the VA!

 

[JackADeli]

I agree with a previous post. My program is heavy in HPB...we do around 30 Whipples during our time, and you definitely see the exposure. Plus, most are done thru subcostal incisions, so it's a similar technique...

Folks keep referencing their open GB experience... as a component of another, larger procedure. It just is not the same thing to do a ~traditional open GB removal through a planned SMALL subcostal incision. Apologies but taking a GB out while doing a liver resection or whipple is just not the same thing.

...I don't think that we will ever "forget" how to do open surgery as residents. There will always be open cases, no matter what. We are a big lap institution but only do 40% of our colorectal cases lap. Not to mention trauma ex laps, redos, conversions, etc. For the record, I've done 65 lap choles and 6 opens (including 5 conversions). And...I've not yet had to convert at the VA!

You have to be taught it or know it in order to forget it. A trauma xlap, etc... is a different game with different exposure as opposed to a planned/non-emergent ~limited open incision procedure.

 

[goooooober]

"So this is sad, but as a PGY-4, I finally did my first open chole."

A little off the subject but I guess you don't rotate at a VA hospital?🙂

Skialta

Agreed, I have NEVER done a lap chole at the VA. Every single one converted to open within 10 minutes of the case starting. I am sad 🙁.

 

[Guile]

Agreed, I have NEVER done a lap chole at the VA. Every single one converted to open within 10 minutes of the case starting. I am sad 🙁.

Yeah I've had the opposite experience. Even in patients with three ex-laps and big adhesions, we were still able to do it laparoscopically.

 

[ESU_MD]

Folks keep referencing their open GB experience... as a component of another, larger procedure. It just is not the same thing to do a ~traditional open GB removal through a planned SMALL subcostal incision. Apologies but taking a GB out while doing a liver resection or whipple is just not the same thing.You have to be taught it or know it in order to forget it.

I remember that it was a rite of passage to do this. The junior would be scrubbed as a 2nd assist (or even 3rd assist) on some big exlap case then when the part of taking out the GB came, the chief/senior would summon junior up to "take out the gallbladder" some would even log the case as a surgeon junior by changing the MR# or something.

not even close to doing an open chole in a hostile acute cholecystitis scenario.

 

[Guile]

the chief/senior would summon junior up to "take out the gallbladder" some would even log the case as a surgeon junior by changing the MR# or something.

Now don't get JAD started on case logging...

 

[JackADeli]

I remember that it was a rite of passage to do this. The junior would be scrubbed as a 2nd assist (or even 3rd assist) on some big exlap case then when the part of taking out the GB came, the chief/senior would summon junior up to "take out the gallbladder" some would even log the case as a surgeon junior by changing the MR# or something.

not even close to doing an open chole in a hostile acute cholecystitis scenario.

Agreed, having the opportunity to do a non-inflamed, open cholecystectomy with massive exposure is a nice step to getting used to some anatomy. However, it does not by itself equate to being trained and/or competent for the isolated, ~elective open cholecystectomy.

As for the junior turning around and fabricating a logged case out of it, that is another topic all together. Though, it does go to the difficulty in accurately assessing resident open surgical experience. Should the ABS/ACS try to determine the true "open" experience, it would be confounded by these deceptive log entries. Based on the handful of replies in this thread alone referencing open cholecystectomy experience.... really just a small part of a liver resection or whipple, it would appear the estimated real experience is possibly very artificially inflated.