Your favorite operations?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
D

Dan Plainview

WFMC
10+ Year Member
Joined
Jan 13, 2011
Messages
36
Reaction score
4
I am a lowly PGY-1, but I am curious as to what y'all's favorite operations are? Personally, I enjoy lap ventral hernias, there's something slick to me about pulling out all that fat (or bowel, or whatever) and tacking (or sewing, or both) the mesh up there and fixing a huge problem through three small incisions. A carotid endarterectomy on a virgin neck is pretty gratifying too, rooting out all that plaque.
Members don't see this ad.
 
  • Like
Reactions: 1 user
VATS lobe and esophagectomy.....going into thoracic. Favorite nonthoracic case is a carotid. The anatomy is sweet and patch is nice to sew and usually not a pta. Favorite general surgical case is a lap nissen/hiatal hernia repair.
 
Dermatological surgery. All that anatomy!
 
Members don't see this ad :)
my top 3

kidney transplant is the most fun. relatively simple, technically interesting, and two great moments, when the kidney gets color, and when the kidney makes urine.
carotid endarterectomy. straightforward, technically interesting, elegant operation, high stakes keeps it interesting.
femoral endartectomy. same reason as carotid.

i'm going into vascular obviously.

lot of fun cases in general surgery that i will miss. trauma splenectomy, lap distal panc, lap adrenal, parathyroidectomy, thyroidectomy, enterolithotomy, straightforward lap chole and lap appy.

considered endocrine surgery but lack of endocrine specific jobs and general aversion to SBO, butt pus, ventral hernias, and other similar gen surg cases kept me away.
 
  • Like
Reactions: 1 user
Glad to see I'm not the only one that thinks the CEA is super sweet. Love seeing the "textbook" anatomy.

Also a fan of amps... something awful powerful about the gigli!

Survivor DO
 
Still just an MS-4, but my favorite has been RPLNDs. By the time the dissection is done it looks like a Netter's slide of retroperitoneal anatomy.
 
I like the anatomy of vascular patients, but I really don't like the pathology that comes with vascular patients. They almost never do "well," unless it was a young patient with a traumatic injury or something.

I do like CEAs, but I also like adhesiolysis :D I would rather pick at a Gordian knot until it came apart instead of taking the Alexandrian approach. Moderately complex ventral hernias are pretty cool too. It's like a puzzle. The loss of domain + EC fistula cases = not cool.

The biggest "wow, that was pretty sweet" operation I did was a nephrectomy. It's simple; you wack it out, and you're looking at some nice retroperitoneal anatomy.
 
Heart transplant....Fly out perform the donor procurement. Put the heart on ice, fly home, sew it in and 4 hours later take the clamp off and almost immediately it starts to beat. I still find it pretty damn amazing each time...
 
I can't believe nobody has mentioned fulguration of anal condyloma....
 
My favorite thing ever is a nice juicy I+D (but not butt pus for a variety of reasons). Especially when it is under pressure and you get a little pus volcano action when you make the initial cut. Loved it as a student, loved it as a resident, and still love it now. Reducing a hernia also gives me the same kind of glee and satisfaction (whether talking about a lap ventral as you lyse all the adhesions and finally get it down, or even nonoperative reduction of the inguinal hernia everyone thought was incarcerated but they were just using bad technique).

I'm a simple gal so I like simple cases I guess.
 
Appendectomy. It simply can't go wrong.... Colectomies are amazing... Never fell in love or even like Lichtenstein, but love to do pediatric hernias. Vascular cases are fun but hate the patient population since they seem never to listen to doctors orders (quit smoking, lose weight, take your ASA) and they die on you....
 
Members don't see this ad :)
My favorite case lately is a laparoscopic approach to bowel incarcerated in a groin hernia. You fix the hernia, often resect the bowel and they have a few small incisions on their belly. The only downside to these cases is that they always seem to happen in the middle of the freaking night.
 
dpmd said:
Reducing a hernia also gives me the same kind of glee and satisfaction (whether talking about a lap ventral as you lyse all the adhesions and finally get it down, or even nonoperative reduction of the inguinal hernia everyone thought was incarcerated but they were just using bad technique).

I'm a simple gal so I like simple cases I guess.
Click to expand...

:love:

Reminded me of one night when the ED called for an "incarcerated" umbilical hernia in an alcoholic with ascites, who was well known to us. A mix of time, patience, and good technique popped that sucker right back in. So satisfying.

I love inguinal hernia repairs, from simple to complex. Especially when I get the opportunity to follow-up with the patient in clinic, they've healed well and are happy with the results.
 
ESU_MD said:
Ever breathe those fumes?
Click to expand...

I'm glad you brought that up. I obviously hate fulgurations as much as the next guy, and the best career advice I ever received was from Rick Billingham, who said "Never give a talk on condyloma," as it's a surefire way to become the regional (or even worse, national) expert on the subject.

I do, however, want to dispel some myths about fulguration cases. I attached a nice review article on the subject that I think everyone should read. It's long, but the punchline is that transmission via electrocautery has never been proven....but transmission via laser plume has....so if your local OBGYN asks for the CO2 laser, start running.


Another article worth a look:
Transmission of HPV to gloves and masks


The other area of interest is the special mask, which does much more to alleviate our fears than it does to actually prevent inhalation of toxic fumes. I was given some horrible news a year ago from my old PD: Because of the increased filtration, air will move preferentially around the N95 mask, entering your mouth through the sides....so unless you're going to have a complete seal (with duct tape on the corners), a regular mask may actually be beneficial. Personally, I feel like I'm suffocating with the N95 mask, so I'm sure I've left the ties a little loose in the past to make breathing easier.....:scared:

Of course, I had no data to back it up...until today. I did a short lit review, and found the following information:

1. Masks aren't doing a good job, and most particles leak through the faceseal.

2. Intensity of filter medium is not nearly as important as the fit of the mask, i.e. a well-fitting regular mask beats out a poorly-fitting special filtration mask.

3. If you're really worried, it's best to take fast, shallow breaths.....


My personal approach is a normal mask (not N95 or other special masks), fit snugly, and regular old electrocautery with the student being Johnny-on-the-Spot with the suction. Another approach I frequently employ is to identify the case as a "resident case" and try to provide some "direct" supervision from the corner of the room.
 

Attachments

  • Surgical smoke Surg Endosc 2003.pdf
    127.4 KB · Views: 88
I really like vascular cases, anything with some sewing especially to restore flow:

1. Trauma femoral or brachial repairs with interposition grafts. I did a primary repair of a radial artery last week, lot of fun.

2. AV fistulas

Really like kidney transplants, relatively fast and usually works right away.

Have to give a shout out for the lap chole, especially when its acute and just a little edematous to really blow up that plane, but not too much that its just stuck and nasty. Just the right amount of juicy....

For some reason I really like doing open G tubes....just go in there and grab the stomach, sew your purse strings, stick in your tube, tack it up and go. Usually plenty of these to go around and no one else wants to do them!
 
Just a student:

Echo the love for vascular cases. CEAs and bypasses of all flavors. Nothing better than a roaring doppler signal or seeing a previously necrotic foot wound become raw and bloody rounding POD#1.

Neck dissections. Like a page from Netter laid out before you.

Open rhinoplasty. Beautiful, delicate work where success or failure is separated by millimeters. Incredibly creative.
 
SLUser11 said:
I'm glad you brought that up. I obviously hate fulgurations as much as the next guy, and the best career advice I ever received was from Rick Billingham, who said "Never give a talk on condyloma," as it's a surefire way to become the regional (or even worse, national) expert on the subject.

I do, however, want to dispel some myths about fulguration cases. I attached a nice review article on the subject that I think everyone should read. It's long, but the punchline is that transmission via electrocautery has never been proven....but transmission via laser plume has....so if your local OBGYN asks for the CO2 laser, start running.


Another article worth a look:
Transmission of HPV to gloves and masks


The other area of interest is the special mask, which does much more to alleviate our fears than it does to actually prevent inhalation of toxic fumes. I was given some horrible news a year ago from my old PD: Because of the increased filtration, air will move preferentially around the N95 mask, entering your mouth through the sides....so unless you're going to have a complete seal (with duct tape on the corners), a regular mask may actually be beneficial. Personally, I feel like I'm suffocating with the N95 mask, so I'm sure I've left the ties a little loose in the past to make breathing easier.....:scared:

Of course, I had no data to back it up...until today. I did a short lit review, and found the following information:

1. Masks aren't doing a good job, and most particles leak through the faceseal.

2. Intensity of filter medium is not nearly as important as the fit of the mask, i.e. a well-fitting regular mask beats out a poorly-fitting special filtration mask.

3. If you're really worried, it's best to take fast, shallow breaths.....


My personal approach is a normal mask (not N95 or other special masks), fit snugly, and regular old electrocautery with the student being Johnny-on-the-Spot with the suction. Another approach I frequently employ is to identify the case as a "resident case" and try to provide some "direct" supervision from the corner of the room.
Click to expand...

This is my opportunity to claim colorectal ignorance and refer out. I figure since I saw/did zero ever in life I will choose not to do it. Not that I never do a case I have never done (thought I did try to talk my first perineal rectosigmoidectomy patient into going to a colorectal specialist but she didn't want to leave town), but why sign myself up for something like that.
 
SLUser11 said:
I'm glad you brought that up. I obviously hate fulgurations as much as the next guy, and the best career advice I ever received was from Rick Billingham, who said "Never give a talk on condyloma," as it's a surefire way to become the regional (or even worse, national) expert on the subject.

I do, however, want to dispel some myths about fulguration cases. I attached a nice review article on the subject that I think everyone should read. It's long, but the punchline is that transmission via electrocautery has never been proven....but transmission via laser plume has....so if your local OBGYN asks for the CO2 laser, start running.


Another article worth a look:
Transmission of HPV to gloves and masks


The other area of interest is the special mask, which does much more to alleviate our fears than it does to actually prevent inhalation of toxic fumes. I was given some horrible news a year ago from my old PD: Because of the increased filtration, air will move preferentially around the N95 mask, entering your mouth through the sides....so unless you're going to have a complete seal (with duct tape on the corners), a regular mask may actually be beneficial. Personally, I feel like I'm suffocating with the N95 mask, so I'm sure I've left the ties a little loose in the past to make breathing easier.....:scared:

Of course, I had no data to back it up...until today. I did a short lit review, and found the following information:

1. Masks aren't doing a good job, and most particles leak through the faceseal.

2. Intensity of filter medium is not nearly as important as the fit of the mask, i.e. a well-fitting regular mask beats out a poorly-fitting special filtration mask.

3. If you're really worried, it's best to take fast, shallow breaths.....


My personal approach is a normal mask (not N95 or other special masks), fit snugly, and regular old electrocautery with the student being Johnny-on-the-Spot with the suction. Another approach I frequently employ is to identify the case as a "resident case" and try to provide some "direct" supervision from the corner of the room.
Click to expand...

From the other end of the digestive tract:

Despite the ability to disperse HPV DNA in laser plume, the evidence suggests that the risk of transmittal of HPV to surgeons and the development of clinically active infection appears to be low. Commercially available filters and masks for use in laser surgery will not afford protection against exposure to HPV, but evacuation of plume from the surgical field is likely an effective strategy to prevent viral contamination. As the use of office-based laser systems and transoral laser procedures increases, the risk to personnel and patients will require more scrutiny.
Click to expand...
 
End of MS-3:

CEA
CABG off-pump
Open AAA (someone has to do 'em)
 
Last edited:
dpmd said:
This is my opportunity to claim colorectal ignorance and refer out. I figure since I saw/did zero ever in life I will choose not to do it. Not that I never do a case I have never done (thought I did try to talk my first perineal rectosigmoidectomy patient into going to a colorectal specialist but she didn't want to leave town), but why sign myself up for something like that.
Click to expand...

How did you do a five year surgical residency and never see an anal wart?

It's quite simple, and I'm not sure you need to refer it out....you just burn them with cautery. The "why" is two-fold: 1) there's a need, and 2) it reimburses well considering how fast and easy it is.
 
SLUser11 said:
How did you do a five year surgical residency and never see an anal wart?

It's quite simple, and I'm not sure you need to refer it out....you just burn them with cautery. The "why" is two-fold: 1) there's a need, and 2) it reimburses well considering how fast and easy it is.
Click to expand...

For the bulk of residency there was no colorectal surgeon and no anal wart patients ever came to clinic (plastics is who they were sent to, but I never saw a case on the schedule to go see). My chief year we had a colorectal guy so that is how I learned to do APR's and tried a few lap colons, but the one warty gal we were going to do (the only one that ever got referred to my clinic) no-showed for her operation. She basically looked like someone had shoved a large cauliflower up her anus. I figured fast and easy would not apply in that case, but I guess I could be wrong. I have to admit I wasn't super excited about doing the case anyway since I was worried about the risk of transmission.
 
ESU_MD said:
I havent seen an off pump CABG in years!
Click to expand...

Question about this:

The OR I worked in before school did chiefly off-pump CABGs. The oldest surgeon there did on-pump but was the only one.

The surgeons where I am now do chiefly on-pump CABGs and there's only one young guy who does off-pump.

Is this just a matter of where and how you trained? Comfort? Certain patients need/require one versus the other? In your opinion, is there a superiority of either technique?
 
MrBeauregard said:
Question about this:

The OR I worked in before school did chiefly off-pump CABGs. The oldest surgeon there did on-pump but was the only one.

The surgeons where I am now do chiefly on-pump CABGs and there's only one young guy who does off-pump.

Is this just a matter of where and how you trained? Comfort? Certain patients need/require one versus the other? In your opinion, is there a superiority of either technique?
Click to expand...

Sounds like a good time for a lit review.

My understanding of the literature is that the off-pump technique never showed a benefit, so it lost popularity over the last 10 years.
 
Favorite cases:
Arterial switch operation
Valve Sparing Aortic Root Replacement
Mitral valve repair
Descending thoracic aortic aneurysm

MrBeauregard said:
Question about this:

The OR I worked in before school did chiefly off-pump CABGs. The oldest surgeon there did on-pump but was the only one.

The surgeons where I am now do chiefly on-pump CABGs and there's only one young guy who does off-pump.

Is this just a matter of where and how you trained? Comfort? Certain patients need/require one versus the other? In your opinion, is there a superiority of either technique?
Click to expand...

I'm going to throw you a bone, because it will be good for me to review the literature for my own education, but you should read about this stuff. Residents frequently want to be taught and just don't read enough. I myself am guilty of not reading enough, but I try to get my 15-30 minutes every night and 3 hours on my day off. Unfortunately, research has to take priority over research every so often.

ROOBY (2009) showed less effective revascularization in follow up. No difference in adverse 30-day mortality, stroke, or dialysis.

There was a scathing editorial in the NEJM about this trial saying that the surgeons didn't have enough experience in OPCAB (Median 50 cases for attending and rersident was primary surgeon in 55%) and that the patients didn't have the risk profile that would push someone towards OPCAB (predicted mortality was <2%, not sure if they used EuroSCORE or STS).

GOPCABE (2013) showed no benefit in terms of stroke, death, dialysis, or MI in patients >75yo. LogEuroscore 8%, Koronarchirurgie score 4%, so a higher risk population than the ROOBY trial.

If you read the chapter in Cohn's about OPCAB, then the subpopulations that would likely show a benefit are: LV dysfunction, EuroScore >5, and a bad aorta (wouldn't want to put a clamp on atheroma).

Finally, you have to consider the difficulty in exposing the PDA and OMs for bypass when you're off pump due to hemodynamic instability. OPCAB can be tough for the anesthesiologist! Then there's the phenomenon of on pump beating heart...
 
I think you are correct, the literature has never shown a clear benefit for OPCABG.
Some centers do have good results with the technique, but on pump is just as good. I dont care what Puskas and his minions say... There is no way to expose and graft an intramuscular distal OM on an enlarged heart off pump, nor is there a reason to try.

When patients ask me about off pump.. I tell them i think it is nice stunt.
 
idiot07 said:
Favorite general surgical case is a lap nissen/hiatal hernia repair.
Click to expand...

Just wait until you get your first Nissen complication -- usually an esophageal or gastric perf. These are some SICK patients.

Trauma Surgeon said:
Appendectomy. It simply can't go wrong....
Click to expand...

Again, just wait. And be on the lookout for zebras. I had a run-of-the-mill appy turn into a jelly-belly with pseudomyxoma at 3 am....

I like a nice trauma spleen.
 
appendectomies can be easter eggs, just as well as choles, as i've heard.
 
I really enjoy the modified Ravitch and the Nuss procedures. Not nearly enough to make me want to do pediatric surgery, but enough that it makes up for a little of the other misery associated with that rotation.
 
1. CEA
2. retroperitoneal AAA
3. debranching :thumbup:
 
Ex-lap for free air.

Something is dead or there's a hole in something that wants to be dead. Or there's a hole in a cancer. They are often so messed up before you operate, that you can bask in all the glory of success and not get as worked up about the failure.

I have to admit that I agree with dpmd as well. I&D, hernia reduction. High benefit, low cost procedures.

You always know you did the right thing with these.
 
Robotic rectopexy with anterior resection.
Port placement
Laparoscopic low anterior (no radiation)
 
You must log in or register to reply here.
Next unread thread

Similar threads

Doctadudeman
What operations requires strict NPO?
Replies
6
Views
2K
Lem0nz
Lem0nz
BonezBonezBonez
What is the favorite thing about your chosen subspecialty?
Replies
9
Views
3K
akwho
A
L
What were your favorite programs?
Replies
0
Views
2K
lilboozie89
L
3
Posture when operating
Replies
8
Views
3K
dpmd
dpmd
J
Share your thoughts on a surgical preference card app idea
Replies
3
Views
718
anonperson
A
Top