The Modified Lithotomy: A Surgical Position for Lower Extremity Wound Care Procedures in Super Morbidly Obese Patients. A Case Study.

Operative positioning of morbidly obese patients presents unique challenges and can cause complications, especially when the operative field involves the proximal lower extremity or genitoperineal region. PURPOSE: The purpose of this case study was to describe a modified lithotomy operative positioning technique that has helped the authors improve care of these patients. METHODS: Double-layer, foam padding at least 4 inches thick is secured to the top and sides of 2 small rolling preparation tables using 3-inch silk tape to create "lithotomy" leg holders, the operating table is raised appropriately, the abducted legs are placed onto the padded prep tables, and the footboard is carefully lowered to provide access to the groin and medial thighs. CASE STUDY: A super morbidly obese (body mass index 74), 47-year-old African American man with a history of hypertension and type 2 diabetes controlled on oral medications presented to the authors' wound care clinic with 2 large, medial left thigh lymphedema masses requiring resection. Both procedures were successfully completed using the modified lithotomy position. No adverse events occurred. CONCLUSION: The modified lithotomy is easy to implement, does not require unique equipment, improves access to the surgical site, and may reduce the risk of complications. Larger and longer-term follow-up studies are needed to monitor the outcomes of this positioning technique.

Partial splenectomy prevents splenic sequestration crises in sickle cell disease.

PURPOSE: Acute splenic sequestrations (SSs) are potentially fatal complications in sickle cell disease (SCD). Total splenectomies in young patients may predispose them to a higher risk of overwhelming infections, whereas partial splenectomy may maintain immunocompetence. We present our series of partial splenectomies in patients with multiple SS episodes. METHODS: We retrospectively reviewed the records of 6 patients who underwent open partial splenectomies for SS. Data on their clinical courses were collected and analyzed. RESULTS: None of the 6 patients had SS postprocedure, down from 2.1 +/- 1.0 (P = .003) sequestrations per year and 3.5 +/- 1.4 (P = .002) total sequestrations per patient. The transfusion requirements were significantly reduced postoperatively (10.2 +/- 5.6 vs 2.0 +/- 3.1 per year; P = .002). There was no increase in the infection-related hospital admissions during the period of follow-up (1.5 +/- 1.8 vs 0.8 +/- 0.8 per year after partial splenectomy; P = .363). The upper pole was preserved in all cases with blood supply off the main splenic artery. CONCLUSIONS: Partial splenectomy decreases the risk of SS in SCD and reduces the need for blood transfusions. Infection rates did not increase after the procedure during the follow-up period. Partial splenectomy should be considered for patients who experience multiple acute SS crises or have long-term transfusion requirements.

Effect of Dakin's solution on components of a dermal equivalent.

BACKGROUND: The use of Dakin's solution on open wounds remains controversial in clinical practice. Here we investigated the effect of Dakin's solution on collagen degradation and fibroblast migration using a dermal equivalent. MATERIALS AND METHODS: Acid solubilized or neutralized collagen was combined with four dilutions of Dakin's solution (0.5%, 0.25%, 0.125%, 0.0125%), with and without serum, at room temperature and 37 degrees C. Collagen degradation was examined at 0, 1, and 24 h using 8% SDS-page gels. Cell migration was determined using dermal equivalents where fibroblasts were incorporated into 3D collagen gels and exposed to Dakin's solution with and without serum. The cells were assessed for viability and cell migration at 24 and 48 h. RESULTS: Dakin's at 0.0125% resulted in little or no collagen degradation compared with a higher concentration of 0.5%, where collagen was either partially or completely degraded. Likewise, cell migration was completely inhibited at higher concentrations, while fibroblasts in a 3D matrix at 0.0125% were still able to migrate at 24 and 48 h, albeit in fewer numbers compared with controls. Serum had a protective effect for both collagen degradation and cell migration when added together with the Dakin's solutions. A time and temperature dependent effect was also noted, with longer contact and higher temperatures being more detrimental. CONCLUSIONS: Collagen degradation and fibroblast migration is affected by the concentration of Dakin's solution, the presence or absence of serum, time exposure and temperature. Use of Dakin's solution in clinical settings should take these findings into consideration in clinical practice.

Factors in fellowship selection: effect of services and fellows.

PURPOSE: General Surgery residents are increasingly pursuing fellowships. We examine whether perceived subspecialty content, dedicated services, and fellows impact fellowship choices. METHODS: Specialty content was assessed through a survey linking 228 operations to 9 content areas. The presence of dedicated services and fellows and the post-residency activities of graduates 1997-2006 were collected from 2 program directors. RESULTS: A total of 75% of residents (26 University of Mississippi, UM; 22 Vanderbilt University, VU) completed surveys. Five dedicated services and 2 fellowships at UM and VU were identical; VU had an additional 4 services and 3 fellowships. UM and VU residents similarly associated 184 operations (81%) with General Surgery. Agreement was not linked to services or fellows. A total of 44% of UM graduates and 68% of VU graduates pursued fellowships. The top choice at UM was Plastic/Hand (14%, versus 6% VU) and Oncology/Endocrine at VU (19%, versus 2% UM). Differences in specialties selected could not be linked consistently to dedicated services or fellows. CONCLUSION: Dedicated services and fellows appear to have little impact on fellowship specialty selection by chief residents. There may be a generic effect of dedicated services favoring fellowship versus no fellowship. Differential faculty mentoring skills may influence specific fellowship choices.

Adding insult to injury: neck exploration for penetrating pediatric neck trauma.

Penetrating neck injuries are uncommon in children, and management involves mandatory exploration of the neck. This results in a number of unnecessary operations. Adult experience is moving towards selective exploration. A retrospective review was performed on all trauma patients presenting over the past 10 years. Pediatric patients with penetrating neck injury were selected and data were collected and analyzed. Out of a total of 19,363 trauma patients over the study period, we identified 39 children with 42 penetrating neck injuries. The average age was 13 years, and 56 per cent of cases were male. A large proportion (72%) was African-American. Over half of the injuries (63%) were from projectiles, including gun shot wounds (59%), which tended to be in the older children, whereas animal bites (5) were noted as a predominant cause in the younger ones. Six patients underwent exploration without any preoperative imaging due to penetration of the platysma, and four of these were nontherapeutic. Eighteen patients with platysma penetration underwent directed preoperative imaging, and 15 avoided operative exploration. CT scans were the most common imaging modality (68%). The median injury severity score was 11. The hospital length of stay was longer in the patients who underwent exploration. Mandatory exploration of the neck in children should not be performed unless clinically indicated. Preoperative imaging should be used liberally to limit nontherapeutic explorations, improve diagnostic accuracy, and reduce morbidity.

Instability of fellowship intentions during general surgery residencies.

PURPOSE: To determine whether PGY-1 future fellowship preferences are stable during progression through residency. METHODS: Residents who took the American Board of Surgery In-Training Examination (ABSITE) were surveyed about fellowships. Three data files were created: categorical and nondesignated preliminary trainees at all postgraduate years (PGY); categorical PGY-1 and chief residents; and individual categorical residents with paired PGY-1 and PGY-5 responses. Gender was self-reported; residency characteristics were retrieved via program identifier codes. Annual frequency distributions were generated by specialty and for other, any fellowship (AF), and no fellowship (NF). RESULTS: Categorical plus contains more than 80,000 responses. Undecided leads PGY-1 intentions at all times, which reached 55% by 2007 and decreased near linearly as PGY level advances. The AF rates increase by PGY level in a decelerating curve. The other rates accelerate at PGY-3 and beyond. The NF rates are low for PGY-1 and 2, nearly double from PGY-3 to 4, and double again from PGY-4 to 5. The categorical group contains more than 20,000 residents with their demographics. The undecided group predominates for both genders, but more women were undecided by 2003. Specialty distribution varies with gender; women were overrepresented in oncology, pediatric, plastic, and other. The undecided group leads choices of university and independent PGY-1 residents, with university overrepresentation in all areas except colorectal, plastic, and no fellowship. Small, medium, and large program PGY-1 residents all choose undecided first but diverge thereafter. Over 12,000 paired categorical PGY-1 and PGY-5 responses reveal that most PGY-1 residents (78%) change future specialties by PGY-5. Undecided residents most often choose no fellowship (25%), vascular (12%), or other (12%). CONCLUSION: PGY-1 residents are increasingly unsure about future fellowships. PGY-1 preferences are unstable whether examined in groups or as individuals. Gender and residency characteristics are linked to differing selection patterns. PGY-1 residents rarely predict accurately their PGY-5 fellowship choices. Early specialization paradigms may disadvantage some residents and residency groups and risk greater attrition rates.

Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery.

BACKGROUND: After completing general surgery residency, surgeons may seek focused additional education or fellowships. Longterm data describing the characteristics of residents selecting fellowships are lacking. Credible data could inform decisions about surgical education paradigms and workforce planning. STUDY DESIGN: From 1993 to 2005, residents taking the American Board of Surgery In-Training Examination were queried about fellowship plans. Individual and residency program data were collected: gender, postgraduate year level (PGY), medical school location (US/international), residency type (academic/community), residency size, and residency location (Northeast, Southeast, Midwest, Southwest, West). The data were examined for changes in the numbers and characteristics of residents seeking fellowships. RESULTS: Responses from 11,080 postgraduate year level-5 residents were analyzed. The number of women nearly doubled and the number of international medical graduates (IMG) almost tripled. Residency program demographics were static. The percentage choosing fellowships increased from 67% to 77%. Patterns of change from "No Fellowship" to "Any Fellowship" were spread heterogeneously across individual and residency subsets. Increases were greatest for Midwest, Southeast, women, community, small program, and US medical graduates. Temporal patterns of change were also heterogeneous. Specialty top choice patterns varied, leading to disproportionate demographic subgroup representation within some specialties. CONCLUSIONS: More general surgery residents are pursuing fellowships. The increase has originated disproportionately from resident and residency demographic subsets and has varied temporally across subgroups. The heterogeneity of change suggests a multifactorial etiology. Future directions in surgical education and workforce planning should reflect these findings.

Gastric electrical stimulation for children with intractable nausea and gastroparesis.

PURPOSE: Gastric electrical stimulation (GES) has been performed in adults as a treatment of refractory nausea and vomiting in patients who have failed medical treatment, but has not been used in children. METHODS: Nine patients with chronic nausea and vomiting with a mean age of 14 years were evaluated for temporary GES. All 9 patients subsequently underwent placement of a temporary followed by permanent GES device. Symptoms were recorded at baseline, after temporary GES, and then after permanent GES using a Likert scale for gastroparesis. Statistical analysis was performed using a paired Student's t test. RESULTS: At baseline, all patients were symptomatic and most had delayed solid gastric emptying. As a group, there was a significant improvement in combined symptoms score (P = .04), nausea (P = .039), and vomiting (P = .0016). Gastric emptying and electrogastrogram values did not change significantly. Follow-up ranged from 8 to 42 months, with 7 of the 9 patients reporting sustained improvement in symptoms and improved quality of life. CONCLUSIONS: Gastric electrical stimulation can be successfully applied to adolescents with intractable nausea and gastroparesis symptoms who fail medical therapy. There is a significant improvement in symptoms over a prolonged period, and there are no adverse effects of the GES. Long-term efficacy of this therapy in children needs to be established.

Recombinant factor VIIa as an adjunct in nonoperative management of solid organ injuries in children.

BACKGROUND: Ongoing bleeding after blunt solid organ injury in children may require invasive therapy in the form of either angiographic or operative control. We report our experience in the use of a procoagulant, recombinant activated factor VII (rFVIIa), for controlling persistent bleeding in blunt abdominal trauma in children. METHODS: After institutional review board approval, the records of 8 children with blunt abdominal trauma, persistent bleeding, and managed nonoperatively with rFVIIa were reviewed. RESULTS: All 8 patients presented to our institution after sustaining blunt abdominal trauma and solid organ injury. All children had evidence of persistent bleeding with a drop in hematocrit and elevation in heart rate. Patients received a single dose of rFVIIa at 75 to 90 microg/kg (1 patient had 24 microg/kg) and had successful control of their bleeding without any further therapeutic intervention. Only 3 patients required a blood transfusion after rFVIIa administration--2 who had subarachnoid hemorrhages and the third during pelvic fixation. There were no cases of thromboembolic events after treatment with rFVIIa. CONCLUSIONS: Recombinant factor VIIa is a useful adjunctive therapy in pediatric patients with evidence of ongoing hemorrhage from blunt abdominal injury and may reduce the need for invasive therapeutic procedures and transfusions.

Face, content, and construct validities of inanimate intestinal anastomoses simulation.

PURPOSE: Surgical simulation modules for "open" surgery are limited and not well studied or validated. Available simulation modules use either synthetic material, which is convenient but may not mimic what is observed or felt in the operating room, or live animal laboratories, which can simulate human tissue but are costly and not readily available. An intestinal anastomosis simulation was devised with thawed porcine intestine. In this study, the face, content, and construct validities of this simulation module were analyzed for both hand-sewn and stapled anastomoses. METHODS: Participants were timed on performing a 2-layered, hand-sewn anastomosis, as well as a side-to-side, functional, end-to-end, stapled anastomosis on thawed porcine small bowel. Anastomoses were examined for adequacy and measured for luminal narrowing and bursting pressure by intraluminal saline infusion. Questionnaires were answered regarding impressions with the simulation modules. Face, content, and construct validities were evaluated by comparing junior residents to senior residents and faculty. Data collected were analyzed with 2-sample t-tests. RESULTS: Both hand-sewn and stapled anastomoses showed strong face and content validity. Overall impressions of these inanimate simulation modules were a positive experience as reflected by the comments of participants. For hand-sewn anastomoses, a significant difference was found between junior and senior group times (50.0 +/- 17.2 vs 33.0 +/- 9.7 minutes, p = 0.013) as well as PGY-1 and faculty times (64.0 +/- 7.2 vs 28.0 +/- 3.8 minutes, p = 0.001). Bursting pressures varied between both groups and were not significant. For stapled anastomoses, no difference was noted between the various groups in completion time or bursting pressure. CONCLUSIONS: Hand-sewn and stapled inanimate intestinal anastomoses are a valid simulation of intraoperative experience based on the face and content validities. Although stapled anastomosis does not have good construct validity, the more challenging hand-sewn anastomosis does differentiate between various skill levels.

See one, do one, be competent in one? Resident rotations broaden the perceived scope of general surgery.

PURPOSE: To compare the scope of general surgery as perceived by general surgery program directors (PDs) nationally and our residents (RES), and to assess the effect of clinical rotation assignments on resident perception. METHODS: A background questionnaire and survey document drawn from the Resident Operative Report submitted by finishing residents to the American Board of Surgery (ABS) was sent to our general surgery residents. Respondents categorized 309 items as procedures with which a finishing resident should be competent (A), familiar (B), or neither (C). Data from an identical survey of PDs were obtained from the ABS. Procedures were assigned to Groups 1-4 based on resident rotations. PD responses were considered the reference data set. RES answers outside the range of 0.5x to 1.5x, where x = PD% for each item, were labeled as different. Differences were categorized as residents having a "narrower" perception of general surgery if RES %A less than 0.5x and %C greater than 1.5x and "broader" if RES %A greater than 1.5x and %C less than 0.5x. Chi-square testing was also performed as a "cross-check" analysis. RESULTS: After eliminating consensus items, 60 Group 1 items, 103 in Group 2, 19 in Group 3, and 16 in Group 4 remained. When linked to resident rotations, RES took a broader view of general surgery scope for 27/163 items and a narrower view for only 1 item (0.6%). Without related rotation experience, RES viewed 0/19 procedures more broadly than PD and categorized 7/19 items more narrowly. When items overlapped 2 surgical specialties, RES assigned no items as broader or narrower. Chi-square testing produced similar results. CONCLUSION: Our residents perceived the scope of general surgery more broadly than did a national sample of PDs for content areas in which residents completed rotations. A broader view of general surgery could influence resident decision making about postresidency fellowships.

Primary laparoscopic repair of high imperforate anus in neonatal males.

PURPOSE: The standard approach to males with high imperforate anus has been a staged procedure starting with a descending colostomy, then posterior sagittal anorectoplasty with colostomy closure after 3 months. Recently, a minimally invasive approach to the repair of high imperforate anus has been described in infants after colostomy. We describe 6 newborn males with high imperforate anus successfully repaired laparoscopically as a primary, single-stage procedure. METHODS: A retrospective chart review was performed on all patients with imperforate anus from October 2003 to October 2006. RESULTS: We evaluated 9 newborn males with high imperforate anus. Of these patients, 6 underwent primary laparoscopic repair on day 1 to day 2 of life. Of these 6 patients, 3 were found to have bladder neck fistulas, whereas the other 3 had prostatic urethra fistulas. All patients passed stool within the first 72 hours postoperatively. One patient has required a procedure for a mild rectal prolapse. Follow-up ranges from 2 to 30 months in the single-stage group. CONCLUSION: Our early results using primary laparoscopic repair appear encouraging. Laparoscopy allows excellent visualization and assessment of the fistula and repair of high imperforate anus without need for colostomy. Long-term follow-up will be needed to assess outcomes and continence rates.