Surgical Potpourri

[SLUser11]

From time to time...in between WAMC threads and questions about "the real top 10".....we have some good clinical discussions here on SDN. Europeman may have an eccentric approach, but he is to be applauded for recently bringing up topics actually related to surgery for us to discuss.

I think it would be nice to have a centralized thread that focuses on clinical questions and scenarios. It can hopefully serve as a back and forth discussion about a multitude of topics.

We'll see how the idea works out. If things start to go bad, I'm okay withdrawing supportive care and allowing a natural thread death. I'll start with my own clinical scenario. I've also listed some previously-discussed topics below.


I'm curious to know what other SDNers think about elective colectomies for patients with diverticulitis. At this point, I'm sure that most of us know the old approach of colectomy after 2 uncomplicated episodes is outdated, and leads to many unnecessary colectomies.

What about after "complicated diverticulitis?" The current expert recommendations are to still recommend elective interval sigmoidectomy after a single episode of complicated diverticulitis. This should be done once the inflammation has cooled down, and the patient has undergone an interval colonoscopy (another area of debatable necessity).

If the complication is obstruction or fistula (colovesicular or colovaginal), then colectomy makes sense because it's necessary to eliminate ongoing symptoms. However, if the complication was just a pelvic abscess, does the patient really need his/her colon out?

We know from the literature that the first episode of diverticulitis is usually the worst, and recurrent episodes are unlikely to progress to emergency surgery. There is, to my knowledge, only one paper that shows patients with abscess to be at a higher risk of a complicated recurrence requiring re-hospitalization or possible emergent surgery.

What is the practice at your institution? Do you think it should be changed?








Here's a list of some recent clinical threads:

Do you ever place a G-tube in patients with ascitis?

What IVF do you give after an elective colectomy?

Are narcotics okay in patients with a SBO?

How do you like to close your 5mm trocar incisions?



Here's a list of some oldies but goodies:

A clinical question for our holiday weekend

A thought provoking case to break the silence

Resurrecting a dead topic: Incidental surgery

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[SLUser11]

I'm curious to know what other SDNers think about elective colectomies for patients with diverticulitis. At this point, I'm sure that most of us know the old approach of colectomy after 2 uncomplicated episodes is outdated, and leads to many unnecessary colectomies.

What about after "complicated diverticulitis?" The current expert recommendations are to still recommend elective interval sigmoidectomy after a single episode of complicated diverticulitis. This should be done once the inflammation has cooled down, and the patient has undergone an interval colonoscopy (another area of debatable necessity).

If the complication is obstruction or fistula (colovesicular or colovaginal), then colectomy makes sense because it's necessary to eliminate ongoing symptoms. However, if the complication was just a pelvic abscess, does the patient really need his/her colon out?

We know from the literature that the first episode of diverticulitis is usually the worst, and recurrent episodes are unlikely to progress to emergency surgery. There is, to my knowledge, only one paper that shows patients with abscess to be at a higher risk of a complicated recurrence requiring re-hospitalization or possible emergent surgery.

I guess I'll answer my own question. I think patients with a history of diverticulitis complicated by pelvic abscess are a heterogeneous group, and not all of them need their sigmoid in a bucket. If they are old with multiple comorbidities, and they did well with their initial conservative management, I may follow them expectantly.

However, if it's a fit patient who can tolerate a colectomy, the only existing literature on the subject shows a higher risk of complicated recurrence, and I'd offer them an elective colectomy. Of course, you could make the argument that an old, frail patient would be less likely to survive a recurrent episode of severe diverticulitis, so it's an overall blurry picture.

On the subject of elective colectomies, as a resident, I did almost all of my sigmoidectomies with a straight laparoscopic technique. As a fellow, I've done my sigmoids 75% hand-assisted and 25% straight lap. I have to admit that when it's a big, heavy, inflamed sigmoid colon, plus or minus a fistula, almost certainly adhesed to the pelvic sidewall, I find the hand-assist approach to be faster and easier...but part of my feels like this is cheating.

For those with experience using both approaches, what will you do in practice, i.e. when the decision is up to you? Will you do straight lap or hand-assist? Lateral to medial, or medial to lateral? Will you place stents routinely for complicated diverticulitis?

 

[Smurfette]

I basically always get the lighted stents in a lap colon case...it's helpful. It's also what we did in residency. Our urologists are great about it.

I start off straight laparoscopic and convert to a hand port if I find myself struggling. However, my hands are SMALL (5 1/2-6 glove), so this is really not a big deal for me to do compared to surgeons with big hands who need a big incision just to get their hands in.

No shame in converting to a hand port IMO...it's about the patient, and if it's safer to put in the hand port, do it. No use in struggling or adding on ridiculous amounts of anesthesia time if it's a nasty, stuck mess. The patients are still happy and still do well. I do tell my patients during consent that I will convert to hand port (or to open) as necessary, especially with a history of complicated diverticulitis.

I do lateral to medial, as I naturally just seem to do it that way, although our CR guys did them medial to lateral where I trained.

 

[blue2000]

I don't have a urologist available to me, so I can't get stents. In residency, we always had urology put stents in, so I have to admit sometimes I'm a little nervous if things are stuck. If there is a colovesicular fistula, I often elect to send those cases down the hill to a place that has a urologist. It's not that I couldn't repair the bladder, it's just that I have no back up in case I need help.

I agree that complicated sigmoid diverticulitis is a heterogeneous disease and there is no one size fits all answer to whether I operate on them and when. I avoid operations in infirm people, though if they are really infirm, it may be worth considering a diverting colostomy.

I do my lap dissections medial to lateral, and I always consent people for conversion to open. In fact for diverticulitis that is quite dense, I consent them for a colostomy as well, and then they're happy if all they end up with is larger incisions (that's slightly facetious, but I do think being clear about expectations is critical in these cases).

 

[SLUser11]

I like the medial to lateral approach, especially for sigmoids, but I have to admit that it seemed quite awkward and foreign at first. Once I got it down, it was way easier and faster.

I think I will use hand-assist selectively for my left colons and LARs, and I'll be quick to place a hand port if the sigmoid is big and inflamed. I plan to use stents liberally at first (advice from my PD), especially since I'm teaching residents.

And now for something completely different: I'm interested to hear what other SDNers think about the use of Statins during abdominal surgery, or in the trauma/ICU scenario. I've attached a nice review article on the subject from the March 2012 JACS.

Statins are relatively benign, with a Rhabdomyolysis number needed to harm of 7,428. There are RCTs in Cardiac and Vascular surgery showing a benefit, but studies in abdominal surgery are all retrospective. Postoperatively, I always continue statins if they are on the home med rec, but obviously I don't start people on them for the hypothetical anti-inflammatory effects. Maybe I should, though....

 

[45408]

I don't have a urologist available to me, so I can't get stents. In residency, we always had urology put stents in, so I have to admit sometimes I'm a little nervous if things are stuck.

Just curious, does any general/colorectal surgeon ever put their own ureteral stents?

I've done it a few times (with a urologist watching), and it really wasn't that hard. Of course, I don't know what I don't know with regard to urology, so I'm just wondering aloud here...

 

[cpants]

Just curious, does any general/colorectal surgeon ever put their own ureteral stents?

I've done it a few times (with a urologist watching), and it really wasn't that hard. Of course, I don't know what I don't know with regard to urology, so I'm just wondering aloud here...

A straightforward stent is pretty easy. The problem is that they are often not so straight forward and there can be complications, sometimes serious. I doubt many CRS guys even want to do this. Not worth the liability for a pretty low paying procedure and the hospital won't privilege you for it anyway most likely.

 

[dynx]

I guess I'll answer my own question. I think patients with a history of diverticulitis complicated by pelvic abscess are a heterogeneous group, and not all of them need their sigmoid in a bucket. If they are old with multiple comorbidities, and they did well with their initial conservative management, I may follow them expectantly.

However, if it's a fit patient who can tolerate a colectomy, the only existing literature on the subject shows a higher risk of complicated recurrence, and I'd offer them an elective colectomy. Of course, you could make the argument that an old, frail patient would be less likely to survive a recurrent episode of severe diverticulitis, so it's an overall blurry picture.

On the subject of elective colectomies, as a resident, I did almost all of my sigmoidectomies with a straight laparoscopic technique. As a fellow, I've done my sigmoids 75% hand-assisted and 25% straight lap. I have to admit that when it's a big, heavy, inflamed sigmoid colon, plus or minus a fistula, almost certainly adhesed to the pelvic sidewall, I find the hand-assist approach to be faster and easier...but part of my feels like this is cheating.

For those with experience using both approaches, what will you do in practice, i.e. when the decision is up to you? Will you do straight lap or hand-assist? Lateral to medial, or medial to lateral? Will you place stents routinely for complicated diverticulitis?

Would and do offer after one complicated presentation. Its the patients choice, I just explain the numbers.

I'd do lap. Its a minority that can't be done straight lap and what do you lose by trying?

Lateral to medial. Not sure if its just a learning curve thing like you mentioned but I got used to going lateral to medial and now it seems like I struggle more when the attending tells me to go medial to lateral.

And no I wouldn't place stents routinely.

 

[SLUser11]

http://journals.lww.com/annalsofsur...cision_Laparoscopic_Cholecystectomy_Is.1.aspx

Just read a recent article summarizing the Single Incision Lap Chole experience. In short, 90.6% of SILCs were done in the absence of cholecystitis, and there was still a bile duct injury rate of 0.72%, which is obviously higher than the published rates for traditional lap and open choles.

I've done a few of these as a resident, and the visualization was always suboptimal. Also, the patients were cherry-picked and I wasn't sure the technique could be applied to the general population. That being said, this was 3+ years ago, and we weren't using any special cameras or instruments.

Is this technique actually dangerous, or are we just on the front end of the learning curve, and the long term results will even out, much like they did for traditional lap choles in the 90's?

 

[blue2000]

http://journals.lww.com/annalsofsur...cision_Laparoscopic_Cholecystectomy_Is.1.aspx

Just read a recent article summarizing the Single Incision Lap Chole experience. In short, 90.6% of SILCs were done in the absence of cholecystitis, and there was still a bile duct injury rate of 0.72%, which is obviously higher than the published rates for traditional lap and open choles.

I've done a few of these as a resident, and the visualization was always suboptimal. Also, the patients were cherry-picked and I wasn't sure the technique could be applied to the general population. That being said, this was 3+ years ago, and we weren't using any special cameras or instruments.

Is this technique actually dangerous, or are we just on the front end of the learning curve, and the long term results will even out, much like they did for traditional lap choles in the 90's?

I don't have any actual data, but my sense is that SILS choles are a whole lot of fanciness for minimal patient benefit and questionable patient harm. Maybe we are on the steep portion of the curve, but I just don't get the reason to do them, other than cosmetic. No real change in pain, return to work, etc, for increased bile duct injuries? I just can't buy in to it. In our small hospital, we've essentially abandoned SILS for appys and choles because it's a whole lot of hard work for minimal benefit.

 

[Dr.LeoSpaceman]

http://journals.lww.com/annalsofsur...cision_Laparoscopic_Cholecystectomy_Is.1.aspx

Just read a recent article summarizing the Single Incision Lap Chole experience. In short, 90.6% of SILCs were done in the absence of cholecystitis, and there was still a bile duct injury rate of 0.72%, which is obviously higher than the published rates for traditional lap and open choles.

I've done a few of these as a resident, and the visualization was always suboptimal. Also, the patients were cherry-picked and I wasn't sure the technique could be applied to the general population. That being said, this was 3+ years ago, and we weren't using any special cameras or instruments.

Is this technique actually dangerous, or are we just on the front end of the learning curve, and the long term results will even out, much like they did for traditional lap choles in the 90's?

I think they're awful. Just so frustrating to do, and not satisfying at all.

And even if we were on the cutting edge and could get the complication rate down to a traditional lap chole, I don't necessarily see the end benefit of accepting it's inferiority in the near term. Moving from open to lap makes sense because of how morbid the subcostal incision is in comparison to some port sites. I consider 5mm's to almost be freebies, so I'm not sure how much you gain by eliminating them.

On the other hand, I like robotic cholecystectomies. Not that there's any benefit, and the cost is certainly not justified. But I'll tell you: it's fun.

 

[Docgeorge]

http://journals.lww.com/annalsofsur...cision_Laparoscopic_Cholecystectomy_Is.1.aspx

Just read a recent article summarizing the Single Incision Lap Chole experience. In short, 90.6% of SILCs were done in the absence of cholecystitis, and there was still a bile duct injury rate of 0.72%, which is obviously higher than the published rates for traditional lap and open choles.

I've done a few of these as a resident, and the visualization was always suboptimal. Also, the patients were cherry-picked and I wasn't sure the technique could be applied to the general population. That being said, this was 3+ years ago, and we weren't using any special cameras or instruments.

Is this technique actually dangerous, or are we just on the front end of the learning curve, and the long term results will even out, much like they did for traditional lap choles in the 90's?

Its ok for the suburban biliary diskinesia gb. People who do SILS on hot GB are braver then me. I also think it is absolutely necessary to have a flexible scope (I like the Olympus over the Stryker) otw it is a miserable experience. I think it's ok as a wratchiting up procedure to build skill before trying SILS colons. Also its a great marketing ploy. If I dont have residents to teach and as I build up enough skill and comfort with it to try to start doing SILS colons I will prob stop doing them. It's a PIA and it makes my wrists hurt. Or I will just do daVinci SILS GB, which is prob the best way to do them, however I really dislike the daVinci Clip appliers that they make for the procedure. I dont have a high degree of confidence in them. I end up tying the cyctic D and A with suture. Unfortunately the daVinci SILS set up is not amiable to do anything ott GBs at this point.

 

[45408]

And even if we were on the cutting edge and could get the complication rate down to a traditional lap chole, I don't necessarily see the end benefit of accepting it's inferiority in the near term. Moving from open to lap makes sense because of how morbid the subcostal incision is in comparison to some port sites. I consider 5mm's to almost be freebies, so I'm not sure how much you gain by eliminating them.

This. I can't think of the last time I saw a complication from the 5mm port, and one of my attendings mentioned recently that no one ever comes in and complains about the scar from one. Seems like getting rid of them is a lot of work with little/no benefit.

 

[Smurfette]

This. I can't think of the last time I saw a complication from the 5mm port, and one of my attendings mentioned recently that no one ever comes in and complains about the scar from one. Seems like getting rid of them is a lot of work with little/no benefit.

I agree. Most patients really don't care about the small lap scars (let's be honest, the vast majority of my chole patients are over 200 lb and aren't exactly worried about how they look in a bikini). I think patients mostly think when it comes to SILS that fewer incisions=less pain, which isn't necessarily the case when you're talking about 5 mm trocars anyway.

I think I read a study a few months back stating that SILS choles had a significantly higher wound complication rate....can't remember the journal, though. Maybe SAGES/surgical endoscopy....

 

[SLUser11]

Or I will just do daVinci SILS GB, which is prob the best way to do them....

I just heard about these from one of the Wichita residents, where they recently started doing them. It sounds intriguing, but apparently you lose some "degrees of freedom" with the current generation. And, to be honest, the same argument could be made for increased wound complication rates. It also turns a 30 minute procedure into a 90 minute (minimum) procedure.

As for a ramping up to a SIL colectomy, that's a whole other issue. I have to admit that I've done some SILCs, but they have all been on chip shot right or left colons (i.e. skinny old ladies with large polyps). SILCs have been proven to be safe and feasible, but they limit the resident's participation in the case, and I'm not excited about making SILCs a big part of my practice.

I haven't used the olympus camera except in the lab, but I think it's safe to say that it takes an educated assistant to do it right. I also haven't used a lot of angled instruments except in TEMS/TAMIS.

I am also from the school of thought that 5's are free. I just can't justify struggling for longer or compromising exposure to eliminate such a small incision. However, I am certain that over the next 10-15 years, we will all be singing a different tune.

 

[Docgeorge]

SILCs have been proven to be safe and feasible, but they limit the resident's participation in the case, and I'm not excited about making SILCs a big part of my practice.
.

Neither am I but I just don't see how I can avoid it and stay competitive.

 

[45408]

I am also from the school of thought that 5's are free. I just can't justify struggling for longer or compromising exposure to eliminate such a small incision. However, I am certain that over the next 10-15 years, we will all be singing a different tune.

I'm not sure. As Smurfette mentioned, most of these patients are getting bigger and bigger. Even if people start to care about scars more (maybe), the technical challenges are only going to increase. Add to that the increasing concerns about cost-savings, and I'd be surprised if many of these things really took off without comparative effectiveness research showing significant improvement.

Granted, where I'm training, I haven't seen any NOTES/SILS of any kind, and the only robotic use I've seen is by other specialties, so I'm not getting any regular exposure to this stuff. I do think the above issues will preclude widespread adoption of things like SILS/NOTES/da Vinci choles.

 

[Dr.LeoSpaceman]

Back to the 5mm port issue, if you were really concerned, I've even used the Stryker 3mm MiniLap instruments. Basically a trocar-less grasper. The skin incision is essentially invisible.

And as junior resident, the SILS colons are frustrating because as mentioned, we essentially don't get to do much. Fortunately, we only have one guy doing them. Not only that, but the the guy is pretty honest about the fact that it's frustrating when he has to re-train a new resident every few weeks to do it. Perhaps it would be different if he did them more frequently, but (like many other people, I imagine) he cherry picks the SILS candidates so there isn't even a chance to get into a rhythm with them.

 

[45408]

Back to the 5mm port issue, if you were really concerned, I've even used the Stryker 3mm MiniLap instruments. Basically a trocar-less grasper. The skin incision is essentially invisible.

First link on that site took me here - http://www.stryker.com/minilapprocedures/minilap_single_incision_hysterectomy.asp

I think I've operated twice on a patient with an abdominal wall like that. I could transilluminate the abdominal wall and place my ports specifically avoiding the clearly outlined vessels. The rest of them look like more like the one on the right:

(as I look closer at that picture, which I've seen posted in our department, I'm noticing that it looks like a Mediport, so of course they would use a cancer patient on the left )

 

[balaguru]

Back in 2009 or so I seem to remember seeing reports of higher pain scores and umbilical hernias in SILS vs conventional lap choles but a quick peek at the new evidence doesn't seem to show that difference anymore--mainly just a difference in operative times. The few SILS choles that I have done were painful and required expensive, hard to find trochars.

http://www.ncbi.nlm.nih.gov/pubmed/22173546

A robotic SILS chole sounds kindof silly.

 

[LucidSplash]

I remember reading this thread as a junior resident and enjoyed the discussion but found myself looking for it again now that I'm a chief and I have some laparoscopic colon cases coming up. Good discussion here and thought I would bump a) for anyone who might not have been around then and b) to ask if SLUser/others have adapted, changed, have any more thoughts on the subjects here 4 years later. Especially medial to lat vs visa versa, etc.

 

[SLUser11]

I remember reading this thread as a junior resident and enjoyed the discussion but found myself looking for it again now that I'm a chief and I have some laparoscopic colon cases coming up. Good discussion here and thought I would bump a) for anyone who might not have been around then and b) to ask if SLUser/others have adapted, changed, have any more thoughts on the subjects here 4 years later. Especially medial to lat vs visa versa, etc.

For complicated diverticulitis, specifically with pelvic abscess, there is very little high-quality data to support your decision. All studies are retrospective, and thus overflowing with selection bias....so the really sick ones get colectomies, and the people who were going to do well regardless tend to do well without colectomy. For me, I still individualize the decision for elective colectomy after Hinchey III diverticulitis, but I definitely operate on more patients than I observe.

As for my surgical approach, I almost never use ureteral stents for elective cancer cases, but I ALWAYS ask for a left-sided ureteral stent for complicated diverticulitis (regular, not lighted, which is gimmicky). No reason for bilateral stents, so I only request a left-sided stent, but it's much easier to place in the beginning than track down a urologist to place them unexpectedly during a tough case. When there's a big phlegmon in the LLQ, and a history of pelvic abscess where the retroperitoneal planes have been altered, the stent can be a wonderful tool. I also work at a teaching institution, and this likely impacts my judgment.

I always start out in a medial to lateral fashion, and rarely have to change approaches, but a good laparoscopic colon surgeon knows all the tricks and is able to troubleshoot when things don't go well. After hundreds of colectomies, I definitely prefer medial to lateral for both left and right-sided resections. It's faster, safer, and ensures a high ligation of the artery. The line of Toldt is the final move, and I often accompany it with inspirational comments to my resident like "sweep the leg" and "is there a problem Dr. Lawrence?" along with "let's put the women and children to bed, and go looking for dinner." The residents don't really understand my obsession with connecting the lateral and medial dissections, but it's my favorite part of the case, and is thus accompanied by lots of quotes from movies they haven't seen.

I've gone back and forth over the last 5 years with hand-assistance. I almost never use hand-assist for right colons, as you want to put the hand where you will extract obviously, and the hand is just in the way the whole time. Still, as mentioned earlier, you have to know all the tricks, and I did a hand-assisted ileocolectomy a few weeks ago for a ridiculous Crohn's phlegmon and saved the patient quite a bit of incision length, so it still has a role.

For sigmoid colectomies, I do most of my cases straight laparoscopic, but I am not a purist! I will place a hand as soon as I think the case will be hard, and I try to make the decision at the very beginning of the case rather than as a "conversion." I use a 5cm pfannenstiel extraction for my straight lap, and for hand assistance this goes up to 8cm, so it's not a big change, but it is certainly different. Despite my massive forearms, I am still able to take down the splenic flexure with this approach without much difficulty, but with occasional alarm beeping from the insufflation machine.

For anyone where the visualization or retraction/exposure is poor (e.g. morbidly obese), I place a hand immediately. For anyone with a sizeable sigmoid phlegmon or densely-adherent fistula, I also place a hand, and there's nothing more satisfying than pinching off a colovesical or colovaginal fistula with a single swipe instead of buzzing blindly at it with cautery for 20 minutes.

In the pelvis, I tend to use the robot, so no hands there.

Overall, I feel that my conversion rate is very low because I plan ahead, and focus on patient positioning, working smarter (not harder).

Hope that helps! If you find yourself in a tough clinical situation, I am also happy to answer questions via PM.