Morris E. Franklin

General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors.

Objective:To assess readiness of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America. Methods:A multidomain, global assessment survey designed by the Fellowship Council research committee was electronically sent to all subspecialty program directors. Respondents spanned minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties. There were 46 quantitative questions distributed across 5 domains and 1 or more reflective qualitative questions/domains. Results:There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.

Laparoscopic-assisted colectomy learning curve

PURPOSE: The purpose of this paper is to establish the number of cases necessary to master laparoscopic removal of the left or right colon. METHODS: Data were obtained by chart review and by individually completed questionnaires. RESULTS: A total of 144 laparoscopic-assisted or intracorporeal right or left hemicolectomies were completed by four surgeons at separate institutions. Questionnaires were completed by each surgeon for each sequential hemicolectomy, and data concerning the type of surgery and total operating time were recorded. Times were plotted to diagram individual learning curves for each surgeon, and data grouping methods were used to determine the curve for each surgeon as well as for the combined data base. Learning was said to have been completed when the surgeons operative time reached a low point and subsequently did not vary by more than 30 minutes. A total of 78 right colectomies and 66 left colectomies were completed by the group. Respectively, each surgeon appeared to learn the procedure after 16, 21, 11, and 6 cases. When the entire database was analyzed as a whole, it was shown that between 11 and 15 completed colectomies were needed for learning, after which operative times remained relatively stable. CONCLUSIONS: This analysis, using total operative time as an indication of learning, shows that approximately 11 to 15 completed laparoscopic colectomies are needed to comfortably learn this procedure.

Laparoscopic surgery for stage III colon cancer: Long-term follow-up

AbstractBackground: The role of laparoscopic surgery in the management of colorectal cancer is controversial. This study was undertaken to determine the oncological adequacy, in terms of margins of resection, lymph node harvest, and anastomotic and locoregional recurrence of laparoscopic colectomy in patients with stage III (node-positive) colorectal cancer. Methods: The results of laparoscopic colectomy in 50 consecutive patients with stage III colorectal cancer operated on at a single hospital between 1991 and 1998 were analyzed with respect to postoperative morbidity, mortality, and long-term survival by the Kaplan-Meier method. Methodical patient follow-up was the mainstay of the study. Results: There were 31 men (52%) and 19 women (38%) with a mean age of 67.7 years (range, 40–88). Low anterior resection was performed in 17 cases, abdominal perineal resection in five cases sigmoid colectomy in 10 cases, left hemicolectomy in six cases, right hemicolectomy in seven cases, transverse colectomy in one case, and subtotal colectomy in four cases. Conversion was necessary in three cases (6%). Major complications included one leak, one pelvic abscess, one perineal wound infection, and three anastomotic strictures early in the experience, with none in the past 4 years. One early death occurred due to massive stroke. Median length of stay was 6 days (range, 3–37). Forty-six patients were staged as CII and four as CI colon cancer. The average number of positive nodes was 5.1 (range, 3–58). The margins of resection were adequate in all patients. Follow-up ranged from 3 to 75 months (average, 29.3; median, 24). Overall cancer-related mortality was 34% (17 patients); three patients died of unrelated causes with no detectable cancer. All who died of cancer had distant disease; three of them also had pelvic recurrence. Mean time of death was 21.7 months. There were no anastomotic recurrences or trocar site implants. Overall 3- and 5-year survival was 54.5% and 38.5%, respectively; cancer-adjusted survival was 60.8% and 49.1%. Conclusions: Based on this study, laparoscopic colectomy in patients with stage III colorectal cancer is oncologically adequate. It results in a long-term outcome comparable to that of traditional open surgery and is associated with low perioperative mortality and morbidity (lower wound infection rate, lower wound recurrences at trocar sites) and a shortened length of stay.

Complications of laparoscopic herniorrhaphy

SummaryAnterior inguinal hernia repair is the second-most-commonly performed abdominal operation and has been associated with low morbidity and mortality rates. The principle of laparoscopy has been applied to this surgical problem in a series of 762 patients with 841 inguinal hernias. Four types of laparoscopic repairs were conducted: (1) high ligation of the indirect inguinal hernia sac and closure of the internal ring (87 patients with 89 hernias); (2) plug and patch of the internal ring (74 patients with 87 hernias); (3) transperitoneal suture repair of the transversalis fascia to the iliopubic tract or Coopers ligament (28 patients with 30 hernias); and (4) placement of a large prosthesis over the myopectoneal orifice (563 patients with 635 hernias). These early results indicate that the overall complication rates were low, especially when a large prosthesis was used to reinforce the myopectoneal orifice. It is concluded that laparoscopic inguinal herniorrhaphy is a safe and effective procedure with which to manage this surgical problem.

Mechanisms of gastric and esophageal perforations during laparoscopic Nissen fundoplication.

OBJECTIVE The purpose of this study was to determine possible mechanisms of 17 gastric and esophageal perforations that occurred during laparoscopic Nissen fundoplication. METHODS Specific details of each perforation relating to mechanism of injury, surgeon experience, diagnosis, treatment, and outcome were obtained. For each perforation, an attempt was made to accurately determine the mechanism of perforation. RESULTS Three mechanisms accounted for the 17 perforations, the majority of which occurred within the first ten laparoscopic Nissen fundoplications performed by the surgeon. Ten perforations resulted from injuries related to improper retroesophageal dissection, five occurred during passage of the bougie dilator or nasogastric tube, and two occurred after surgery secondary to suture pullthrough. Six patients received a delayed diagnosis, which adversely affected outcome. Most of the perforations were successfully managed by primary closure and wrap to include the repair. Morbidity was significantly increased for perforations recognized late. One death, attributed to sepsis, occurred in association with a delay in diagnosis. CONCLUSIONS Gastric and esophageal perforations are serious complications of the new laparoscopic method of Nissen fundoplication. The mechanisms of these complications are specifically related to limitations of the laparoscopic technique. Prevention of these potentially lethal complications requires a full understanding of the detailed anatomy of the gastroesophageal region and awareness of the recognized mechanisms of perforation.

Transvaginal extraction of the specimen after total laparoscopic right hemicolectomy with intracorporeal anastomosis.

Laparoscopic surgery for colonic disease has experienced an increased utilization by surgeons owing to decreased morbidity, less pain, earlier ambulation, earlier bowel function, fewer complications, decreased narcotic use, and improved cosmesis compared with open colon surgery. Current techniques require an abdominal incision, albeit smaller than an open laparotomy incision, which increases pain and complication rates such as infection, hernia development, and a less pleasing cosmetic result. The ability to perform a totally intracorporeal anastomosis will be an initial step to allow surgeons to perform natural orifice colon surgery in the future. One benefit of the intracorporeal anastomosis technique is that the only incision needed is for trocar placement. By combining the 2 techniques of totally intracorporeal anastomosis and transvaginal extraction of the specimen, surgeons will have the option to perform a totally laparoscopic colectomy on female patients. This case study describes a patient with a transvaginal route of specimen extraction after an oncologic laparoscopic right colon resection with intracorporeal anastomosis. It is the intent to further advance the technical options in the field of natural orifice surgery with the description of this technique. After completing a totally laparoscopic right colectomy with intracorporeal anastomosis and transvaginal extraction, an excellent postoperative recovery was demonstrated and has shown future potential for natural orifice surgery.

Laparoscopic diagnosis and treatment of intestinal obstruction

Background: Intestinal obstruction is a common reason for general surgical referral. The traditional approach has been conservative management, followed by laparotomy if conservative measures are unsuccessful. However, with the advent of minimally invasive surgery, the need for laparotomy for this common problem is being challenged.Methods: From May 1991 to April 2001, 167 patients underwent laparoscopy for diagnosis and/or treatment of intestinal obstruction. Average patient age was 62 years (range, 21–98). The site of obstruction was the stomach in seven patients, small bowel in 116 patients, and colon in 44 patients.Results: Laparoscopy successfully diagnosed the site of obstruction in all patients. In addition, 154 patients (92.2%) were successfully treated laparoscopically without conversion to laparotomy. Both intraoperative and postoperative complication rates were low (3.5 and 18.6%, respectively) and compared favorably with those of published reports.Conclusions: Intestinal obstruction can be approached safely and effectively by laparoscopy with the intent not only to correctly diagnose the patient but also to render treatment.

Morbidity of laparoscopic surgery for complicated appendicitis: an international study.

BackgroundAlthough laparoscopic appendectomy has some advantages over open appendectomy, some reports do show more postoperative intraabdominal abscesses.MethodsA retrospective review of complicated appendicitis managed surgically by eight surgical groups from six countries was undertaken. Among 3,433 patients with appendicitis, 1,017 (29.5%) had complicated appendicitis, which included perforated or gangrenous appendicitis with or without localized or disseminated peritonitis. There were 74 preoperative abscesses (7.4%) and 5 small bowel obstructions.ResultsOne patient died. There were 29 postoperative intraabdominal abscesses (2.8%) and 112 mostly minor complications. Conversion to laparotomy was necessary for 28 patients (2.7%). The surgical time ranged from 32 to 132 min (mean, 62 min), and the hospital stay ranged from 1 to 18 days (mean, 3.5 days).ConclusionsThe morbidity rates, particularly for intraabdominal abscesses, were less for laparoscopic appendectomy in complicated appendicitis than those reported in the literature for open appendectomy, whereas operating times and hospital stays were similar.

How to prevent port-site metastases in laparoscopic colorectal surgery.

Abstract. Various reports concerning port-site metastasis after laparoscopic surgery for colorectal cancer have created a new concern regarding the use of this technique for the treatment of this malignancy. The real incidence is not yet known; neither are its prognostic implications. Numerous experimental studies, both in vitro and in vivo, have been published since 1994. These studies have analyzed the possible role of pneumoperitoneum and carbon dioxide (CO2) and pathophysiology, as well as the influence of minimally invasive techniques on tumor response and immunity. There are no definitive results yet, but there is enough evidence to presume that the etiology of this new complication might derive from surgical technique. We present our 8-year experience with laparoscopic surgery for colorectal cancer. We also review our technique for preventing port-site implants. At this writing, we have had no port metastasis in our series of 320 colorectal cancer cases with a mean follow-up period of 54 months. The steps we follow as a routine in all cases of laparoscopic colorectal cancer are (a) fixation of trocars to the abdominal wall, (b) avoidance of touching the tumor, (c) high vascular ligation, (d) intraoperative colonoscopy and intraluminal irrigation with 5% iodine povidone, (e) specimen isolation before extraction from the abdominal cavity, and (f) intraperitoneal and trocar-site irrigation with a tumoricide solution.

Laparoscopically monitored colonoscopic polypectomy: an established form of endoluminal therapy for colorectal polyps

BackgroundBenign polyps, the most common disorders of the colon, are considered by many to be premalignant lesions. Colonoscopy is widely used to remove the majority of these polyps. However, a variety of “difficult polyps” are not accessible for colonoscopic removal because of their location and size, the tortuosity of the colon, or the complexity of the lesion (sessile vs pedunculated). In the past, a formal segmental resection usually was suggested for these difficult polyps.MethodsFor 110 patients with a median age of 73 years, a total of 149 polyps were removed as follows: 88 from the right colon, 18 from the transverse colon, 10 from the left colon, and 33 from the rectosigmoid colon. Pathologic evaluation showed adenomatous polyps in 13 patients (11.81%), hyperplastic polyps in 1 patient (0.9%), adenocarcinomas in 10 patients (9.09%), carcinoma in situ in 1 patient (0.9%), and adenomas in the remaining patients (tubulovillous, 40.18%; villous, 19.31%, and tubular, 17.77%). All the specimens were evaluated for margins and depth of resection.ResultsThe median size of the polyps was 2.30 cm (range, 0.2–6 cm). The average hospital stay was 1.14 days, with a liquid diet started 6 h postoperatively. Mild abdominal pain/trocar-site pain was the most common complaint. The patients were followed with colonoscopy 6 months postoperatively and yearly thereafter.ConclusionsA combined endoscopic–laparoscopic approach provides a valid alternative for treating difficult colonic polyps and eliminating the morbidity of a segmental resection. This approach seems to be safe and effective.