Tag Archives: laparoscopic surgery

Colorectal Surgery: Fast-Track Recovery

Enhanced Recovery After Surgery (ERAS) protocols have been hyped as “simple solutions” for accelerating recovery after colonic resection, although the quantity and quality of evidence supporting their ability to improve periopertive care and decrease postoperative complications is limited, Dr. Mary-Anne Aarts said in a presentation at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in San Antonio last week. 

Image via Flickr user praction^r by Creative Commons License.

One ERAS metric that shows consistent improvement across the available studies, however, is hospital length of stay, said Dr. Aarts who, along with her colleagues in the department of surgery at the University of Toronto, have identified (via a retrospective study of 366 consecutive colorectal resection patients at seven University of Toronto hospitals) the five “most important” ERAS strategies that contribute to the success in this domain.

These include:

  1. Preoperative counseling regarding early discharge.
  2.  Omission of an oral bowel movement preparation.
  3. Use of a laparoscopic approach.
  4. Initiation of clear fluids on day of surgery.
  5. Early discontinuation of the Foley catheter.

While the identification of these strategies does not address the quality of care and complication issues that have to be evaluated in large, prospective, collaborative studies before ERAS protocols will be widely accepted, it offers specific targets for investigation, which in turn could streamline research efforts, according to Dr. Aarts. 

–Diana Mahoney

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Filed under Family Medicine, Gastroenterology, Geriatric Medicine, Hospice and Palliative Care, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Practice Trends, Surgery, Uncategorized

Hysterectomy Disconnect

At least two-thirds of hysterectomies in the United States are still performed through an abdominal incision, despite the availability of minimally invasive approaches that are associated with less pain, shorter hospital stay, more rapid recovery, and better cosmesis. In an attempt to change that, the AAGL  Advancing Minimally Invasive Gynecology Worldwide has just issued a position statement calling for nearly all hysterectomies that are done for benign uterine disease to be performed vaginally or laparoscopically, rather than abdominally.

"TAH" stands for Total Abdominal Hysterectomy. Image courtesy of Intuitive Surgical Inc.

According to the AAGL, the few contraindications to laparoscopic hysterectomy (LH) include conditions in which the risks of general anesthesia or intraperitoneal pressure are deemed unacceptable or where uterine malignancy is suspected. For both LH and vaginal hysterectomy (VH), exceptions include situations where trained surgeons or required facilities are unavailable, or in certain cases of distorted anatomy.

Otherwise, AAGL said, “When hysterectomy is necessary, the demonstrated safety, efficacy, and cost-effectiveness of VH and LH mandate that they be the procedures of choice.” 

So why aren’t they?  After all, in some European countries the rate of abdominal hysterectomy (AH) is less than 25%.  Interesting insight can be found in the results of a recently published online/paper survey sent to a random sample of 1,500 practicing U.S. obstetrician-gynecologists.

Among the 376 who responded, the most commonly performed hysterectomy procedure in the previous year was AH (by 84% of respondents), followed by VH (76%).  But when asked to rank which hysterectomy approach they would prefer for themselves or their partner, 56% ranked VH as their first choice and 41% ranked LH as their first choice, with only 8% opting for AH. 

When asked about barriers to performing minimally invasive procedures, the most common ones reported for VH included technical difficulty, potential for complications, and personal caseload. For LH, respondents cited lack of training during residency, technical difficulty, personal surgical experience, and operating time as barriers. 

Nonetheless, when asked about their ideal goal for mode of access, the respondents felt on average that minimally invasive techniques should comprise 79% of all hysterectomy procedures. 

According to the AAGL’s position statement, “Surgeons without the requisite training and skills required for the safe performance of VH or LH should enlist the aid of colleagues who do, or should refer patients requiring hysterectomy to such individuals for their surgical care.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Filed under Anesthesia and Analgesia, Family Medicine, Geriatric Medicine, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Obstetrics and Gynecology, Plastic Surgery, Practice Trends, Surgery, Uncategorized

Colon Surgery Has Aged Well

“The nearly 300-year history of surgery of the colon is replete with creative daring among surgeons who conquered the challenges of operating on this highly contaminated organ, housed in the sacrosanct peritoneal cavity.”

Left hemicolectomy - Next! Photo by Flickr user Steve Thornton

That’s how Dr Alvin M. Cotlar began his 2002 treatise on the history of colon surgery, published in the Journal of Current Surgery. His record begins in 1710, with a French surgeon who examined the body of a baby who died from complications of imperforate anus. “He suggested that a deliberate colostomy might be done, bringing both ends out through an abdominal incision, with the proximal end a permanent anus.”

We can only imagine the experience of patients who underwent colostomies and ilesotomies as treatment for both diverticulitis and cancer throughout the 18th- and 19th centuries. Without antibiotics and anesthetics, the outcomes had to be no less than grim.  Dr. Cotlar quotes one surgeon’s wry observation of seven colorectal surgeries with dismal outcomes: “Facts are always useful, and if none of them deserve to be regarded as guides to success, at least some have value as a warning against failure.”

Things had improved a little – but not much – by 1925, when today’s 85 year-olds arrived on the scene. Dr. Fred Rankin of Lexington, Ky.  observed that surgery for diverticulitis was “unquestionably more difficult from the standpoint of technique and immediate mortality, than malignancy.”

What would these surgeons have made of two studies presented at the annual meeting of the Society of Gastrointestinal and Endoscopic Surgeons, (SAGES) which found that patients in their 80s could not only survive colorectal and paraesophageal hernia surgery, but do so with less than a cup of blood loss, an incision barely 4 inches long, and a hospital stay of  jsut a few days? Since I didn’t have any 110-year-old surgeons to provide perspective, I asked my 90-year-old dad.

He described his 1943 inguinal  hernia operation at Wright-Patterson Air Force Base – one of the first ever to use mesh in a repair. At a vigorous 23 years old, my dad still spent more than 2 weeks recuperating in the hospital.  Last year -when he was 89 – Dad had a hernia recurrence, this time bilateral. He was treated at our local outpatient surgery unit, home with a couple band aids on his belly barely 12 hours after he set foot in the door.

My dad clearly is a fine example of the point both SAGES studies eloquently drive home: Age need not be a barrier to laparoscopic surgeries that can improve health even in some of our oldest patients. While laparoscopy may not yet be quite up to Dr. McCoy’s Star Trek surgery, it’s still fine enough to earn Spock’s salute: Live long and prosper!

— Michele G. Sullivan (on Twitter: @MGsullivan)

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Filed under Family Medicine, Geriatric Medicine, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Oncology, Primary care, Surgery, Uncategorized