The subspecialization of surgery: a paradigm shift.

General surgery has become increasingly fragmented into subspecialties and diseases previously treated by general surgeons are now managed by "specialists". The Resident Education Committee of the Society for Surgery of the Alimentary Tract (SSAT) has reviewed the history of surgical training and factors that have contributed to this evolution to subsepcialization. As it is unlikely that this paradigm shift is reversible, a clear understanding of the contributing factors is essential. Herein, we present a timeline and taxonomy of forces in this evolution to subspecialization.

Impact of advanced laparoscopy courses on present surgical practice.

BACKGROUND AND OBJECTIVES: The introduction of new surgical techniques has made training in laparoscopic procedures a necessity for the practicing surgeon, but acquisition of new surgical skills is a formidable task. This study was conducted to assess the impact of advanced laparoscopic workshops on caseload patterns of practicing surgeons. METHODS: After we obtained institutional review board approval, a survey of practicing surgeons who participated in advanced laparoscopic courses was distributed; the results were analyzed for statistical significance. The courses were held at the University of Nebraska Medical Center between January 2002 and December 2010. Questionnaires were mailed, faxed, and e-mailed to surgeons. RESULTS: Of the 109 surgeons who participated in the advanced laparoscopy courses, 79 received surveys and 30 were excluded from the survey because of their affiliation with the University of Nebraska Medical Center. A total of 47 responses (59%) were received from 41 male and 6 female surgeons. The median response time from completion of the course to completion of the survey was 13.2 months (range, 6.8-19.1 months). The mean age of participating surgeons was 39.2 years (range, 29-51 years). The mean time since residency was 8.4 years (range, 0.8-21 years). Eleven surgeons had completed a minimal number of laparoscopic cases in residency (<50), 17 surgeons had completed a moderate number of laparoscopic procedures in residency (50-200), and 21 surgeons had completed a significant number of cases during residency (>200). Of the surgeons who responded, 94% were in private practice. Fifty-seven percent of the participating surgeons who responded reported a change in laparoscopic practice patterns after the courses. Of these surgeons, 24% had a limited residency laparoscopy exposure of <50 cases. Surgeons who were exposed to ≥50 laparoscopic cases during their residency showed a statistically significant increase in the number of laparoscopic procedures performed after their class compared with surgeons who did not receive ≥50 laparoscopic cases in residency (P = .03). In addition, regardless of the procedures learned in a specific class, surgeons with ≥50 laparoscopic cases in residency had a statistically significant increase in their laparoscopic colectomy and laparoscopic hernia procedure caseload (P < .01). However, there was no statistically significant difference in laparoscopic caseload between surgeons who had completed 50 to 200 laparoscopic residency cases and those who had completed greater than 200 laparoscopic residency cases (P = .31). Furthermore, the participant's age (P = .23), practice type (P = .61), and years in practice (P = .22) had no statistical significance with regard to the adoption of laparoscopic procedures after courses taken. This finding is congruent with the findings of other researchers. Future interest in advanced laparoscopy courses was noted in 70% of surgeons and was more pronounced in surgeons with ≥50 cases in residency. CONCLUSION: Advanced laparoscopic workshops provide an efficacious instrument in educating surgeons on minimally invasive surgical techniques. Participating surgeons significantly increased the number of course-specific procedures that they performed but also increased the number of other laparoscopic surgeries, suggesting that a certain proficiency in laparoscopic skills is translated to multiple surgical procedures. Laparoscopy experience of ≥50 cases during residency is a strong predictor of an increase in the number of advanced laparoscopic cases after attending courses.

Discharge disposition after pancreatic resection for malignancy: analysis of national trends.

OBJECTIVES: The aim of this study is to analyse national trends in discharge disposition following pancreatic resection for malignancy in the USA. METHODS: The Nationwide Inpatient Sample database was queried for 1993-2005 to identify patients who underwent pancreatic resection for malignancy. The status of patients at discharge (to home, home with home health care or to another facility) was noted. RESULTS: A weighted total of 51 866 patients who underwent pancreatectomy for malignant neoplasm of the pancreas were identified. Patients who died in the postoperative period and patients without a specified discharge disposition were excluded, leaving 43 603 patients for inclusion in the study. Overall mortality improved over the period of the study from 7.1% in 1993 to 5.2% in 2005. The number of patients discharged to another facility increased significantly from 5.5% in 1993 to 13.3% in 2005. Similarly, the number of patients discharged to home with home health assistance increased from 20.0% in 1993 to 33.0% in 2005. This corresponded with a statistically significant decrease in the number of patients discharged to home without assistance, from 74.5% in 1993 to 53.7% in 2005 (P= 0.002). CONCLUSIONS: The results of our study demonstrate that following pancreatic resection for malignancy, nearly half the patients will require some assistance after discharge.

Retention of fundamental surgical skills learned in robot-assisted surgery.

Evaluation of the learning curve for robotic surgery has shown reduced errors and decreased task completion and training times compared with regular laparoscopic surgery. However, most training evaluations of robotic surgery have only addressed short-term retention after the completion of training. Our goal was to investigate the amount of surgical skills retained after 3 months of training with the da Vinci™ Surgical System. Seven medical students without any surgical experience were recruited. Participants were trained with a 4-day training program of robotic surgical skills and underwent a series of retention tests at 1 day, 1 week, 1 month, and 3 months post-training. Data analysis included time to task completion, speed, distance traveled, and movement curvature by the instrument tip. Performance of the participants was graded using the modified Objective Structured Assessment of Technical Skills (OSATS) for robotic surgery. Participants filled out a survey after each training session by answering a set of questions. Time to task completion and the movement curvature was decreased from pre- to post-training and the performance was retained at all the corresponding retention periods: 1 day, 1 week, 1 month, and 3 months. The modified OSATS showed improvement from pre-test to post-test and this improvement was maintained during all the retention periods. Participants increased in self-confidence and mastery in performing robotic surgical tasks after training. Our novel comprehensive training program improved robot-assisted surgical performance and learning. All trainees retained their fundamental surgical skills for 3 months after receiving the training program.

National trends in discharge disposition after hepatic resection for malignancy.

BACKGROUND: There is a paucity of data on the trends in discharge disposition for patients undergoing hepatic resection for malignancy. AIM: To analyse the national trends in discharge disposition after hepatic resection for malignancy. METHODS: The National Inpatient Sample (NIS) database was queried (1993 to 2005) to identify patients that underwent hepatic resection for malignancy and analyse the discharge status (home, home health or rehabilitation/skilled facility). RESULTS: A weighted total of 74,520 patients underwent hepatic resection of whom, 53,770 patients had a principal diagnosis of malignancy. The overall mortality improved from 6.3% to 3.4%. After excluding patients that died in the post-operative period and those with incomplete discharge status, 45,583 patients were included. The proportion of patients that had acute care needs preventing them from being discharged home without assistance increased from 10.9% in 1993 to 19.5% in 2005. While there was an increase in the number of patients discharged to home health care during this time (8.9% to 13.8%), there was a larger increase in the proportion of patients that were discharged to a rehabilitation or skilled nursing facility (2% to 5.7%). Despite a decrease in the mortality rates, there was no improvement in rate of patients discharged home without assistance over the period of the study. CONCLUSIONS: The results of the present study demonstrate that after hepatic resection, a significant proportion of patients will need assistance upon discharge. This information needs to be included in patient counselling during pre-operative risk and benefit assessment.

Multipurpose surgical robot as a laparoscope assistant.

BACKGROUND: This study demonstrates the effectiveness of a new, compact surgical robot at improving laparoscope guidance. Currently, the assistant guiding the laparoscope camera tends to be less experienced and requires physical and verbal direction from the surgeon. Human guidance has disadvantages of fatigue and shakiness leading to inconsistency in the field of view. This study investigates whether replacing the assistant with a compact robot can improve the stability of the surgeon's field of view and also reduce crowding at the operating table. METHODS: A compact robot based on a bevel-geared "spherical mechanism" with 4 degrees of freedom and capable of full dexterity through a 15-mm port was designed and built. The robot was mounted on the standard railing of the operating table and used to manipulate a laparoscope through a supraumbilical port in a porcine model via a joystick controlled externally by a surgeon. The process was videotaped externally via digital video recorder and internally via laparoscope. Robot position data were also recorded within the robot's motion control software. RESULTS: The robot effectively manipulated the laparoscope in all directions to provide a clear and consistent view of liver, small intestine, and spleen. Its range of motion was commensurate with typical motions executed by a human assistant and was well controlled with the joystick. CONCLUSIONS: Qualitative analysis of the video suggested that this method of laparoscope guidance provides highly stable imaging during laparoscopic surgery, which was confirmed by robot position data. Because the robot was table-mounted and compact in design, it increased standing room around the operation table and did not interfere with the workspace of other surgical instruments. The study results also suggest that this robotic method may be combined with flexible endoscopes for highly dexterous visualization with more degrees of freedom.

Does type of mesh used have an impact on outcomes in laparoscopic inguinal hernia?

BACKGROUND: Theoretically, a lighter and softer mesh may decrease nerve entrapment and chronic pain by creating less fibrosis and mesh contracture in laparoscopic inguinal hernia repair. METHODS: We performed a telephone survey of patients who underwent laparoscopic inguinal hernia surgery between 2001 and 2007. We recorded patient responses for chronic pain, foreign body sensation, recurrence, satisfaction, and return to work, and then studied the effect of type of mesh (polypropylene vs polyester) on these factors. RESULTS: Of 109 consecutive patients surveyed (mean age, 54.5 y), 67 eligible patients underwent 84 transabdominal extraperitoneal procedures and 2 transabdominal preperitoneal procedures. Patients with polypropylene mesh had a 3 times higher rate of chronic pain (P = .05), feeling of lump (P = .02), and foreign body perception (P = .05) than the polyester mesh group. Our overall 1-year recurrence rate was 5.9%. The recurrence rate was 9.3% for the polypropylene group and 2.9% for the polyester group (P = .26). CONCLUSIONS: A lightweight polyester mesh has better long-term outcomes for chronic pain and foreign body sensation compared with a heavy polypropylene mesh in laparoscopic inguinal hernia repair. We also saw a trend toward higher recurrence in the polypropylene group.

Miniature in vivo robotics and novel robotic surgical platforms.

Robotic surgical systems, such as the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, California), have revolutionized laparoscopic surgery but are limited by large size, increased costs, and limitations in imaging. Miniature in vivo robots are being developed that are inserted entirely into the peritoneal cavity for laparoscopic and natural orifice transluminal endoscopic surgical (NOTES) procedures. In the future, miniature camera robots and microrobots should be able to provide a mobile viewing platform. This article discusses the current state of miniature robotics and novel robotic surgical platforms and the development of future robotic technology for general surgery and urology.

Marginal mandibulectomy: 11 years of institutional experience.

PURPOSE: Literature on marginal mandibulectomy deals mainly with floor of mouth cancers. The purpose of the present study was to evaluate the oncologic outcome of marginal mandibulectomy in buccal sulcus cancer as compared with floor of mouth cancer. PATIENTS AND METHODS: Chart review of 179 patients who underwent marginal mandibulectomy during 1993 to 2003 at Tata Memorial Hospital yielded 161 marginal mandibulectomies done for squamous cell carcinoma (SCC). Oncologic outcomes in terms of disease control and cause-specific survival for the gingival buccal and tongue/floor of mouth cancers were compared. Independent impact of various prognostic factors on the local control and cause-specific survival was evaluated using Cox proportional hazards model. RESULTS: A total of 137 marginal mandibulectomies were done for SCC in gingival buccal complex and 24 for floor of mouth SCC. Bone was microscopically involved in 13 (8.1%) cases and mucosal margin of excision showed tumor in 12 (7.5%) cases. However, they had no influence on locoregional failure or cause-specific survival. Cause-specific survival at 2 and 5 years was 85.6% and 72.2%, respectively. Cause-specific survival at 5 years was significantly better for buccal cancer than floor of mouth cancer (P = .041). On multivariate analysis patients with floor of mouth cancer were at a 3 times higher risk of dying of disease than those with buccal cancer. CONCLUSION: In carefully selected patients, marginal mandibulectomy in buccal sulcus cancer achieves at least as good local control and survival as compared with the floor of mouth cancer.

Ectopic thyroid cancer.

Ectopic thyroid tissue may be encountered anywhere from the foramen caecum to the lower neck. It is rarely seen in the mediastinum. True malignant transformation in ectopic thyroid tissue is extremely rare. Such a malignancy is virtually always diagnosed after surgical excision of the lesion at pathological examination. We report on an extremely rare case of true mediastinal thyroid cancer in a 45-year-old woman. The clinicopathologic features and diagnosis of the lesion, with regard to its mediastinal location are discussed.