Is obesity a contraindication for kidney donation?

INTRODUCTION: To enlarge the donor pool, kidney donors with obesity have been considered. We hypothesized that it is safe for patients with obesity to serve as living kidney donors. METHODS: In this single-center retrospective analysis, we examined the effect of obesity (body mass index (BMI) of 30-35 kg/m2) on glomerular filtration rate (GFR) and creatinine in patients undergoing laparoscopic donor nephrectomy. Other outcomes included intraoperative, 30-, and 90-day complications. We examined the trajectory between patients with obesity versus patients without obesity over time using mixed effects models for the outcomes of creatinine in mg/dL and GFR in mL/min/1.73 m2. RESULTS: Among donors with obesity versus donors without obesity, there were no significant differences in demographics or comorbidities. Baseline creatinine in donors with obesity was significantly greater than that of donors without obesity (p = 0.02). Operative time was significantly longer in donors with obesity versus without obesity (p = 0.03). There was no significant difference in 30-day morbidity between donors with obesity versus without obesity (6.52 vs. 3.57%, respectively; p = 0.38). The rate of graft complications was 8.7% in donors with obesity versus 7.1% in donors without obesity (p = 1.0). 90-day complications were infrequent, and not significant different between the groups. At 6, 12, and 24-month postoperative follow-up, the mean creatinine level in patients with obesity was not significantly different from that of patients without obesity (1.23 vs. 1.31, 1.23 vs. 1.26, and 1.17 vs. 1.19 at 6, 12, and 24 months, respectively). Mean GFR was also not significantly different at 6, 12, and, 24 months. CONCLUSION: Postoperative creatinine and GFR changes were not significantly different in patients with obesity versus without obesity after laparoscopic donor nephrectomy. These findings suggest that carefully screened living kidney donors with obesity do not experience decreased postoperative renal function.

Outcomes of robot-assisted versus laparoscopic repair of small-sized ventral hernias.

INTRODUCTION: The aim of the study is to investigate the outcomes of the da Vinci robot-assisted laparoscopic hernia repair of small-sized ventral hernias with circumferential suturing of the mesh compared to the traditional laparoscopic repair with trans-fascial suturing. METHODS: A retrospective review was conducted of all robot-assisted umbilical, epigastric and incisional hernia repairs performed at our institution between 2013 and 2015 compared to laparoscopic umbilical or epigastric hernia repairs. Patient characteristics, operative details and postoperative complications were collected and analyzed using univariate analysis. Three primary minimally invasive fellowship trained surgeons performed all of the procedures included in the analysis. RESULTS: 72 patients were identified during the study period. 39 patients underwent robot- assisted repair (21 umbilical, 14 epigastric, 4 incisional), and 33 patients laparoscopic repair (27 umbilical, 6 epigastric). Seven had recurrent hernias (robot: 4, laparoscopic: 3). There were no significant differences in preoperative characteristics between the two groups. Average operative time was 156 min for robot-assisted repair and 65 min for laparoscopic repair (p < 0.0001). The average defect size was significantly larger for the robot group [3.07 cm (1-9 cm)] than that for the laparoscopic group [2.02 cm (0.5-5 cm)] (p < 0.0001), although there was no significant difference in the average size of mesh used (13 vs. 13 cm). There was no difference in patients requiring postoperative admission or length of stay between the two groups. The mean duration of follow-up was 47 days. There was no difference in complication rate during this time, and no recurrences were reported. CONCLUSION: There are no significant differences in terms of safety and early efficacy when comparing small-sized ventral hernias repaired using the robot-assisted technique versus the standard laparoscopic repair.

Comparison of Single-Port Robotic Donor Nephrectomy and Laparoscopic Donor Nephrectomy.

Purpose: To compare the intra- and postoperative outcomes of single-port robotic donor nephrectomies (SP RDNs) and laparoscopic donor nephrectomies (LDNs). Materials and Methods: We retrospectively reviewed our institutional database for patients who received LDN or SP RDN between September 2020 and December 2022. Donor baseline characteristics, intraoperative outcomes, postoperative outcomes, and recipient renal function were extracted and compared between LDN and SP RDN. SP RDN learning curve analysis based on operative time and graft extraction time was performed using cumulative sum analysis. Results: One hundred forty-four patients underwent LDN and 32 patients underwent SP RDN. LDN and SP RDN had similar operative times (LDN: 190.3 ± 28.0 minutes, SP RDN: 194.5 ± 35.1 minutes, p = 0.3253). SP RDN patients had significantly greater extraction times (LDN: 83.2 ± 40.3 seconds, SP RDN: 204.1 ± 52.2 seconds, p < 0.0001) and warm ischemia times (LDN: 145.1 ± 61.7 seconds, SP RDN: 275.4 ± 65.6 seconds, p < 0.0001). There were no differences in patient subjective pain scores, inpatient opioid usage, or Clavien-Dindo II+ complications. Short- and medium-term postoperative donor and recipient renal function were also similar between the groups. SP RDN graft extraction time and total operative time learning curves were achieved at case 27 and 13, respectively. Conclusion: SP RDN is a safe and feasible alternative to LDN that minimizes postoperative abdominal incisional scars and has a short learning curve. Future randomized prospective clinical trials are needed to confirm the findings of this study and to identify other potential benefits and drawbacks of SP RDNs.

What circumstances prompt a workplace discussion in medical evaluations for back pain?

PURPOSE: To determine how frequently workplace topics emerge in the interactions between patients and providers in an evaluation for low back pain (LBP) and to determine its association with patient and provider characteristics. METHODS: Adults with work-related LBP (N = 97; 64 % male; median age = 38) completed a demographic questionnaire and a survey of disability risk factors, then agreed to audio-taping of their visits with a participating occupational healthcare provider (n = 14). Utterance-level verbal exchanges were categorized by trained coders using the Roter interaction analysis system. In addition, coders flagged any instance of workplace discussion between patients and providers. RESULTS: Workplace discussions occurred in 51 % of visits, and the most frequent topic was physical job demands. Workplace discussions were more frequent among the oldest and youngest patients and when patients were seen by providers who were more patient-centered and made more efforts to establish patient rapport and engagement. However, patients reporting numerous disability risk factors and workplace concerns in the pre-visit questionnaire were no more likely to discuss workplace topics with their providers (p > 0.05). Only the patient-centered orientations of providers and patients remained statistically significant predictors in multivariate modeling (p < 0.05). CONCLUSIONS: Workplace discussions are facilitated by a patient-centered orientation and by efforts to establish patient engagement and rapport, but workplace discussions are no more frequent among patients with the most significant workplace concerns. Screening questionnaires and other assessment tools may be helpful to foster workplace discussions to overcome possible barriers for returning to work.

Management of Staple Line Leaks after Laparoscopic Sleeve Gastrectomy.

Background and Objectives: Laparoscopic sleeve gastrectomy has become one of the most popular bariatric surgeries in the United States with a low rate of morbidity and effective weight loss. However, staple line leak remains a feared complication requiring a lengthy and difficult treatment course until resolution. This study outlines the various treatment methods used within a high-volume bariatric practice for successful leak resolution without necessitating a conversion procedure. Methods: A retrospective review was conducted on all patients with staple line leak after laparoscopic sleeve gastrectomy in a three-surgeon bariatric practice from January 1, 2010 to December 31, 2019. Results: A total of 10 staple line leaks were identified with a leak rate of 0.9%. Patients presented on average 29.3 days postoperatively and were all diagnosed on computed tomography. Three patients were initially managed operatively with washout and drainage procedure. Six patients were managed endoscopically initially with either stent or over-the-scope clip placement. Most patients required multiple interventions with an average of 2.4 interventions per patient. Average time to leak resolution was 48.2 days (15-95 days). Conclusion: Management of staple line leaks after laparoscopic sleeve gastrectomy requires a multimodal approach usually requiring multiple interventions before leak resolution. We demonstrate effective utilization of varying interventions that lead to effective leak resolution and avoid conversion operations.

Combined robotic-assisted laparoscopic prostatectomy and laparoscopic hemicolectomy.

A 60-year-old man with prostatic adenocarcinoma and a synchronous tubulovillous adenomatous polyp of the colon underwent a successful robotic radical prostatectomy combined with a laparoscopic right hemicolectomy. We describe the initial report of this combined, minimally invasive procedure involving separate organ systems and surgical disciplines, and describe our technique.

Laparoscopic single site adrenalectomy using a conventional laparoscope and instrumentation.

BACKGROUND AND OBJECTIVES: We present a case of Laparoendoscopic Single Site Surgery (LESS) left adrenalectomy performed with a conventional laparoscope and instruments. METHODS: A 45-year-old male was diagnosed with hyperaldosteronism. Computed tomography detected a left adrenal nodule. Bilateral adrenal vein sampling was consistent with a left-sided source for hyperaldosteronism. RESULTS: Total operative time for LESS left adrenalectomy was 120 minutes. The surgery was performed with conventional instruments, a standard 5-mm laparoscope, and a SILS port, with no additional incisions or trocars needed. No complications occurred, and the patient reported an uneventful recovery. CONCLUSIONS: LESS adrenalectomy is a feasible procedure. Although articulating instruments and laparoscopes may offer advantages, LESS adrenalectomy can be done without these.

Laparoendoscopic single site (LESS) splenectomy with a conventional laparoscope and instruments.

BACKGROUND AND OBJECTIVES: We present 2 cases of laparoendoscopic single site surgery (LESS) splenectomy performed with a conventional laparoscope and instruments, and the use of a novel internal retraction device. METHODS: One patient underwent LESS splenectomy for idiopathic thrombocytopenia purpura (ITP), and a pediatric patient with sickle cell disease underwent LESS splenectomy and cholecystectomy. In each case, a 2-cm vertical incision was made within the confines of the umbilical ring, and a SILS port (Covidien, Norwalk CT) inserted. A 5-mm, 30-degree laparoscope and standard 5-mm instruments were used. After isolation of the splenic hilum, one 5-mm trocar of the SILS port was upsized to 12mm, and a laparoscopic stapler was used to divide the splenic artery and vein. An internal retractor consisting of a laparoscopic bulldog clamp with a hook attachment was used to retract the gallbladder, and to secure the specimen retrieval bag during splenic extraction, which eliminated the need for a fourth trocar. RESULTS: Total operative time was 160 minutes for the LESS splenectomy, and 216 minutes for the LESS splenectomy and cholecystectomy. Both procedures were successfully completed with conventional instrumentation and a SILS port, without the need for additional incisions or trocars. No complications occurred, and both patients had an uneventful recovery. CONCLUSIONS: LESS splenectomy is a feasible procedure that can be performed safely. Although articulating instruments and laparoscopes may offer advantages, they are not necessary for performing LESS splenectomy.

Polyester composite versus PTFE in laparoscopic ventral hernia repair.

INTRODUCTION: Both polyester composite (POC) and polytetrafluoroethylene (PTFE) mesh are commonly used for laparoscopic ventral hernia repair. However, sparse information exists comparing perioperative and long-term outcome by mesh repair. METHODS: A prospective database was utilized to identify 116 consecutive patients who underwent laparoscopic ventral hernia repair at The Mount Sinai Hospital from 2004-2009. Patients were grouped by type of mesh used, PTFE versus POC, and retrospectively compared. Follow-up at a mean of 12 months was achieved by telephone interview and office visit. RESULTS: Of the 116 patients, 66 underwent ventral hernia repair with PTFE and 50 with POC mesh. Patients were well matched by patient demographics. No difference in mean body mass index (BMI) was demonstrated between the PTFE and POC group (31.8 vs. 32.5, respectively; P=NS). Operative time was significantly longer in the PTFE group (136 vs.106 minutes, P<.002). Two perioperative wound infections occurred in the PTFE group and none in the POC group (P NS). No other major complications occurred in the immediate postoperative period (30 days). At a mean follow-up of 12 months, no significant difference was demonstrated between the PTFE and POC groups in hernia recurrence (3% vs. 2%), wound complications (1% vs. 0%), mesh infection, requiring removal (3% vs. 0%), bowel obstruction (3% vs. 2%), or persistent pain or discomfort (28% vs. 32%), respectively (P=NS). CONCLUSION: Our study demonstrated no significant association between types of mesh used and postoperative complications. In the 12-month follow-up, no differences were noted in hernia recurrence.

Factors that predict outcome of abdominal operations in patients with advanced cirrhosis.

BACKGROUND & AIMS: Patients with cirrhosis have an increased risk of complications during surgery that is relative to the severity of liver disease; it is a challenge to determine which patients are the best candidates for surgery. We performed a hospital-based study to identify factors that might facilitate selection of operative candidates and guide their management. METHODS: A retrospective review was performed of 100 cirrhotic patients (50 classified as Child-Turcotte-Pugh [CTP] A, 33 as CTP B, and 17 as CTP C) who underwent abdominal surgery at an institution specializing in liver medicine and transplant from 2002-2008. Significant univariate variables were evaluated by multivariate logistic regression models to identify factors that correlate with outcome. RESULTS: The overall, 30-day postoperative mortality rate was 7%. The mortality for patients who were CTP A was 2%, CTP B was 12%, and CTP C was 12%; 33 patients had a Model for End-Stage Liver Disease (MELD) score >or=15, with 29% mortality. On the basis of multivariate analyses, risk factors for adverse outcome were American Society of Anesthesiologists (ASA) score >3; procedures being emergent; intraoperative blood transfusion; intraoperative blood loss >150 mL; presence of ascites; total bilirubin level >1.5 mg/dL; and albumin level <3 mg/dL. Addition of serum albumin to MELD score showed that patients with MELD score >or=15 and albumin 2.5 mg/dL) had significantly increased mortality (60% vs 14%, P < .01) and independently increased probability of adverse outcome (odds ratio, 8.4; P = .015). CONCLUSIONS: For patients with MELD scores >or=15, the preoperative albumin level correlates with outcome and could guide operative decisions. Intraoperative packed red blood cell transfusion correlates with adverse outcome and should be limited.

Laparoscopic and open reversal of Hartmann's procedure--a comparative retrospective analysis.

BACKGROUND: Restoration of intestinal continuity after Hartmann's procedure has traditionally required laparotomy. This study compares our experience with laparoscopic and open reversal of Hartmann's procedure. STUDY DESIGN: All laparoscopic and open Hartmann's reversal procedures performed between January 1998 and June 2006 were reviewed. Patients with laparoscopic reversal were retrospectively matched by age, body mass index (BMI), and indication to controls with open reversal. Demographic data, perioperative course, and postoperative complications were documented. RESULTS: We identified 41 patients who underwent laparoscopic reversal of Hartmann's procedure and these were matched to 41 patients with open reversal. The groups had similar average age and BMI. The predominant indication for surgery in both groups was diverticular disease. Conversion to laparotomy occurred in eight patients (19.5%), and was due to dense adhesions or difficulty in identification of the rectal stump. Adhesions were significantly greater in the conversion group (p <0.05), and the rectal stump was not marked in any of these cases. The most common short-term complications were ileus and surgical site infection. There were no anastomotic leaks and no mortalities. The mean operative times in the laparoscopic and open groups were 193 versus 209 min, respectively (p = 0.33). The laparoscopic group had a significantly lower estimated blood loss of 166 versus 326 mL (p < 0.0005), shorter time to bowel function return (4.1 versus 5.2 days, p < 0.05), and a shorter hospital stay (6.4 versus 8.0 days, p < 0.05). The major complication rate was also significantly lower in the laparoscopic group than in the open group (4.8% versus 12.1%, p < 0.05). CONCLUSIONS: Laparoscopic reversal of Hartmann's procedure is a safe and practical alternative to open reversal. It can be performed with similar operative time, fewer complications, and a faster recovery time. Conversion during the reversal procedure was significantly impacted by severity of adhesions and marking of the rectal stump.

Laparoscopic removal of a large gastric trichobezoar in a 4-year-old girl.

BACKGROUND: Standard treatment of large gastric bezoars not amenable to medical or endoscopic management is surgical removal. The optimal operative approach, laparotomy versus laparoscopy, is a contested subject. Though laparoscopic removal has been described, it remains a relatively new technique for surgical management with outcome literature limited to case reports. In addition, currently described laparoscopic techniques often involve limited midline laparotomy incisions or >3 cm extensions of port sites. METHODS: The following describes the case of a 4-year-old girl with a large gastric trichobezoar. RESULTS: The gastric trichobezoar was successfully removed through a 12-mm left lower quadrant trocar incision cosmetically hidden within a skin crease. CONCLUSION: This case, along with accumulating literature, supports the use of laparoscopy to treat large gastric bezoars.

Laparoscopic resection of giant adrenal cavernous hemangioma.

BACKGROUND: Large adrenal tumors were initially believed to be a relative contraindication to laparoscopic adrenalectomy. METHODS: Here we discuss the case of a 42-year-old female with a 12-cm adrenal mass. RESULTS: The patient underwent successful laparoscopic resection, and pathology revealed a cavernous hemangioma, a rare benign tumor of the adrenal gland. CONCLUSION: The following is a discussion of the case, laparoscopic resection technique, and brief review of adrenal hemangiomas. In experienced hands, adrenal mass size should not be considered a contraindication to laparoscopic intervention.

Renal Safety of Intravenous Ketorolac Use After Donor Nephrectomy.

INTRODUCTION: The benefit and short-term safety of ketorolac have been established in previous studies however, the risk of bleeding and long-term renal impairment in patients undergoing donor nephrectomy remain unclear. We report our experience at a high-volume transplant center. METHOD: Between January 1996 and January 2014, 862 consecutive patients underwent laparoscopic donor nephrectomy. Exclusion criteria included nonsteroidal anti-inflammatory drug allergy, asthma, bleeding disorders, long-term opioid use, intraoperative blood loss >700 mL, peptic ulcer disease, bleeding diathesis, and baseline creatinine greater than 1.9 mg/dL. Intravenous ketorolac was administered within 30 minutes following the surgical procedure at a dose of 15 to 30 mg every 6 hours. Patients were categorized into 2 groups according to the administration of ketorolac after surgery. Differences between the groups were analyzed. Primary outcomes were changes in serum creatinine and hemoglobin levels. Poor outcome was defined as postsurgical complications. RESULTS: During this time, 469 (55.3%) received ketorolac. The mean donor age was 39 years, and 360 (42.5%) were male. Left kidneys were procured in 82%. Operative time averaged 210 minutes and warm ischemia time117 seconds. Baseline demographic and operative outcomes were comparable in both groups. No statistically significant differences were found between the ketorolac group and the nonketorolac group in preoperative and postoperative hemoglobin levels and serum creatinine at 1 week, 1 year, and 5 years (P = .6). Ketorolac use was not associated with increased perioperative morbidity (P = NS). CONCLUSION: The use of intravenous ketorolac in patients undergoing donor nephrectomy was not associated with an increased risk of bleeding or renal impairment.

Detection of papillary thyroid carcinoma with serum protein profile analysis.

OBJECTIVE: To determine the sensitivity and specificity of surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF-MS) for papillary thyroid carcinoma (PTC) detection. DESIGN: The SELDI-TOF-MS protein profiles of patients with PTC, patients with benign nodular disease (BND), and healthy controls were analyzed to determine the sensitivity and specificity of SELDI-TOF-MS assay for PTC detection. Data analysis was performed to process the spectral data and classify the disease status of the patients. SETTING: Academic tertiary care hospital. PATIENTS: Serum samples were collected prospectively from 7 patients with PTC, 8 patients with BND, and 7 healthy control volunteers. INTERVENTION: All patients diagnosed as having PTC or BND underwent thyroidectomy from October 21, 2004, to January 31, 2006. MAIN OUTCOME MEASURES: Twenty-two serum samples were analyzed. RESULTS: Most protein peaks resolved by the SELDI-TOF-MS assay were in the range of 1 to 20 kDa. Classification tree analysis based on peak expression distinguished patients with PTC from those with BND with 85.7% sensitivity and 100% specificity. Serum samples from patients with PTC differed most significantly from those of patients with BND by the underexpression of a protein peak at 11 101 Da. CONCLUSIONS: This pilot study demonstrates that proteomic analysis of serum protein profiles distinguishes patients with PTC from patients with BND with a high degree of sensitivity and specificity. Further investigation into the clinical utility of this technology in PTC biomarker detection and surveillance is warranted.

Laparoscopic cortical-sparing adrenalectomy for bilateral pheochromocytoma.

A 32-year-old female with asthma was hospitalized for pneumonia in 2/06. She underwent a CT scan of the chest which revealed an incidental finding of bilateral adrenal masses. On further questioning, she admitted to palpitations and flushing. She was normotensive. Biochemical workup was significant for elevated urinary norepinephrine and normetanephrines, and plasma catecholamine level. MIBG scan showed positive uptake in the left adrenal gland consistent with pheochromocytoma. T2 weighted MRI showed bilateral adrenal masses, left greater than right. After adequate alpha blockade with phenoxybenzamine, the patient underwent a laparoscopic left adrenalectomy. Pathology revealed a 3.5 cm pheochromocytoma. The patient then underwent a right cortical-sparing adrenalectomy to avoid complete adrenal insufficiency and Addisonian crisis. The choice of operation was made realizing the potential for increased bleeding, which was further complicated by the patient's Jehovah's Witness beliefs, which prohibit transfusion of any blood products. At surgery, a small, well-circumscribed mass of the inferior right adrenal gland was found, and excised in its entirety. A postoperative ACTH-stimulation test showed appropriate cortisol response. Pathology revealed a 1.5 cm pheochromocytoma, and the patient recovered uneventfully. Cortical-sparing adrenalectomy has been reported with success rates of 65-100% in avoiding exogenous steroid dependence.(1,2) Bilateral pheochromocytoma remains the most common indication. Risks for both recurrence and malignancy require lifelong follow-up in these patients.

Recurrence after laparoscopic ventral hernia repair: a prospective pilot study of suture versus tack fixation.

Mesh fixation in laparoscopic ventral hernia repair requires the use of tacks and/or permanent transabdominal sutures. Sutures pass through all fascial and muscle layers of the anterior abdominal wall, whereas tacks secure the mesh simply to peritoneum. Controversy exists regarding the optimal fixation method. In this pilot study, we compared recurrence rates between these two techniques. Patients undergoing laparoscopic ventral hernia repair at the Mount Sinai Medical Center were prospectively and nonrandomly enrolled in the study and underwent either suture-fixation or tack-fixation. Office charts, computed tomography, and telephone interviews were used to determine recurrence events. chi2 and Student's t tests were performed to compare group characteristics and multivariate Cox regression analysis was used to assess for recurrence predictors after adjusting for potential confounders. From 2004 to 2005, 27 patients had suture repairs and 21 had tack repairs. The two groups had similar demographic, history, and operative variables. At a mean follow-up of 18 months, the recurrence rate was 14 per cent. In multivariate analyses, fixation method did not significantly affect recurrence. In this pilot study, patients undergoing laparoscopic ventral hernia repair with primarily transabdominal sutures or tacks experienced similar recurrence rates. Future studies will be needed to validate these findings.

Robotic-assisted vs. laparoscopic donor nephrectomy: a retrospective comparison of perioperative course and postoperative outcome after 1 year.

Safety is of utmost importance in live donor nephrectomies. In this study, we describe our initial experience with robot-assisted laparoscopic donor nephrectomy (RDN) in comparison with the standard laparoscopic donor nephrectomy (LDN). We retrospectively reviewed 95 patients who either underwent RDN or LDN performed by a single surgeon from 2011 to 2016 at a tertiary institution. Donor perioperative course and postoperative outcome along with recipient outcomes were compared. Of the 95 cases, 73 were classified as LDN and 22 were classified as RDN. There were no significant differences between the two groups in age, sex, BMI, race, and ASA status. Operative times (p < 0.001) were longer in the RDN group, but eventually approached LDN times. Warm ischemia (p = 0.002) and extraction times (p = 0.05) were also longer in the RDN cohort. The donor length of hospital stay, complication rates, and postoperative change in eGFR from baseline were similar in both cohorts up to 1 year. Recipient outcomes, including delayed graft function, graft failure, and renal function up to 1 year, were also comparable. In this study, we compared the longest postoperative course so far in both donors and recipients between RDN and LDN. Up to 1 year, RDN does not negatively impact outcomes. Proficiency with RDN also quickly improved to match LDN, making it a suitable procedure for newer surgeons.

Cosmetic thyroid surgery: defining the essential principles.

OBJECTIVES: Minimally invasive thyroid surgery is rapidly becoming a common approach in busy endocrine surgery practices. The surgical concepts necessarily include a number of principles found within the realm of plastic surgery. DESIGN: The study was a prospective, nonrandomized analysis of a consecutive series of thyroid surgical patients. METHODS AND MATERIALS: All patients who underwent thyroid surgery at the Medical College of Georgia in the Department of Otolaryngology were prospectively evaluated. Recommendations for endoscopic thyroidectomy, minimally invasive nonendoscopic thyroidectomy (MINET), or conventional thyroid surgery were based on patient and disease parameters as previously described. Specific factors contributing to improved cosmetic outcomes were sought. RESULTS: Two hundred forty-eight patients underwent thyroidectomy between September 2003 and June 2006. There were 50 males and 198 females, with a mean age of 44.9 +/- 14.6 years. Seventy-seven (31.0%) patients underwent conventional thyroidectomy (group A), 120 (48.4%) patients had MINET (group B), and the remaining 51 (20.6%) patients underwent thyroidectomy with an endoscopic technique (Group C). Incision lengths were 92.4 +/- 22.3 mm in Group A, 46.4 +/- 9.9 mm in Group B, and 24.3 +/- 5.9 mm in Group C. The factors that contributed most to an optimal cosmetic result were marking the patient while he or she was sitting up prior to surgery, resecting skin edges during closure, avoidance of subplatysmal flap elevation and drains, and use of Dermabond. CONCLUSIONS: Achieving an optimal cosmetic result when performing thyroid surgery is easiest when oneapplies a number of principles, including elements normally associated with plastic surgery.

Emerging trends in the performance of parathyroid surgery.

OBJECTIVE: The management of hyperparathyroidism has evolved rapidly in the past decade with the introduction of intraoperative parathyroid hormone testing, radioguided surgery, and endoscopic surgery. Not surprisingly, there is a corresponding movement toward specialization of surgeons providing increasingly sophisticated treatments for head and neck endocrine disorders. We sought to identify trends in the disciplines performing parathyroid surgery. DESIGN: Nonrandomized, controlled comparison of surgical caseloads and publication volumes. METHODS AND MATERIALS: Two metrics designed to reflect the proportion of parathyroidectomies being performed by otolaryngologist-head and neck surgeons (OHNS) and general surgeons (GS) were chosen: the operative case logs of graduates from American training programs in OHNS and GS from 1996 through 2005 and the number of scientific papers published relating to parathyroid surgery during two timeframes (1991-1995 and 2001-2005). RESULTS: There was a gradual increase in the mean number of parathyroid surgeries performed by GS residents from 6.0 in 1996 to a peak of 9.2 in 2004; this volume has begun to decline (to 8.5 in 2005). During the same timeframe, the mean number of parathyroidectomies performed by OHNS residents rose sharply and steadily from 1.8 in 1996 to 10.9 in 2005. The number of American GS parathyroid publications from 1991 to 1995 was 41, compared with 108 in the period 2001 to 2005. During the same timeframe, the number of American OHNS parathyroid papers increased from 1 to 27. The relative proportion of parathyroid publications authored by American otolaryngologists rose from 2.4% to 20.0% (P = .006). CONCLUSIONS: Increasingly, otolaryngologists are the primary surgeons in parathyroid operations as indicated by two surrogate metrics. Graduating chief residents in otolaryngology now perform more parathyroid procedures than chief residents in general surgery, and a growing proportion of parathyroid publications are being authored by otolaryngologists.