John Blair Deaver’s War on the prostate

Shattering Glass Ceilings: Three Black Women Surgeons Ascend to Chairs of Departments of Surgery.

BackgroundAnalyzing the representation of specialties within professional surgical societies provides insight into differences in specialty composition across professional organizations. This study compares membership by surgical specialty in the American College of Surgeons (ACS) and Society of University Surgeons (SUS) to national counts.Study DesignACS data was sourced from 2024 ACS Fellowship Statistics while SUS member data was sourced from their public member directory. Proportions of specialties within ACS and SUS were compared to national representation (active board certificates). Analyses were performed across ACS-recognized surgical subspecialties to evaluate differences in representation between ACS, SUS, and national distributions.ResultsThis study analyzed 59,148 ACS Fellows, 1574 SUS members, and 201,820 active board-certified surgeons, revealing significant differences in the representation of surgical specialties across these categories (P < 0.001). In contrast to general surgery and specialties that require a formal general surgery training, many surgical subspecialties were represented at proportions lower than their national board certification distributions in the ACS and SUS.ConclusionThis study revealed significant differences in surgical subspecialty representation within larger professional surgical societies. Targeted efforts improving engagement across surgical fields is imperative to promote representation and facilitate collaborative efforts.

Mandate for Accreditation in Plastic Surgery Ambulatory/Outpatient Clinics

Fission and fusion in the field of surgery.

Using Surgical Video to Improve Technique and Skill.

Pleurectomy and decortication (PD) in malignant pleural mesothelioma has a high morbidity mostly associated with aspiration pneumonia (PNA), deep vein thrombosis (DVT), and foreign catheter sepsis. We instituted four strategies to reduce these complications and report our experience. This was a retrospective review of patients who underwent PD at the University of Pennsylvania between 2015 and 2022. Our patients underwent standard of care PD in addition to tracheostomy and gastrostomy/jejunostomy tube with therapeutic anticoagulation (AC) leading up to surgery. Measured outcomes were postoperative PNA, DVT, and sepsis. The predicted risk of those same outcomes had patients not undergone the interventions was calculated based on the American College of Surgeons (ACS) surgical risk calculator (SRC). A McNemar's test was used to determine whether the risk of having PNA, DVT and sepsis differed between the two subgroups. Fifty-five patients were included in the study. The mean age was 70 years (SD 6.2) with a mean of 21 (SD 19) pack-years of smoking. PNA, DVT, and catheter-related sepsis occurred in 12, four, and seven patients, respectively. Upon using the ACS SRC prediction model of the nonintervention group, PNA, DVT and catheter related sepsis was predicted to occur in 24 (paired data OR 5, 95% CI: 1.4-17.2; McNemar's test p = 0.008), 14 (paired data OR 3.5, 95% CI: 1.15-10.6; McNemar's test p = 0.03), and 17 (paired OR 3, 95% CI: 1.09-8.3; McNemar's test p = 0.04) patients, respectively. Patients undergoing tracheostomy creation, therapeutic AC at the time of diagnosis, and gastrostomy tube placement had a reduced risk of aspiration PNA, DVT, and catheter sepsis.

Edward E. Cornwell III, MD, FACS, FCCM

International Trauma Anesthesia and Critical Care Society (ITACCS).

Minimally Invasive Surgery and the Novel Coronavirus Outbreak: Lessons Learned in China and Italy.

Patient-Centered, Gynecology-Specific Prioritization of Nonurgent Surgeries during the COVID-19 Pandemic: Proposal of a Novel Scoring System

Dr. Stanley Klatsky was born in Wilmington, Delaware. When Stanley was 8 years old, during World War II, his father was drafted into the Navy and the family moved to Baltimore. After high school, he enrolled at the University of Maryland School of Pharmacy, graduating in 1955. By that time, Stanley had decided he wanted to be a physician. While on duty at the Army Reserve at Fort Sam Houston, Texas, he began applying to medical schools and, following his active duty tour, he worked as a pharmacist in downtown Baltimore while awaiting acceptance. Interestingly, he had filled prescriptions for Dr. Harry Linden (who was in the first graduating class of The Johns Hopkins School of Medicine), and Dr. Linden supported his application to medical school. Stanley also met his wife Rosalie (Fig. 1) during this time; they were married in 1960, and subsequently had two sons, Alan and Mark (Fig. 2).Fig. 1.: Stanley and Rosalie Klatsky at an Aesthetic Society event (left) and more recently at another formal event (right). (Photographs courtesy of the Klatsky family.).Fig. 2.: Stanley Klatsky and his family. Stanley and Rosalie Klatsky, and their sons Alan and Mark (left). Dr. Klatsky enjoying a recent dinner with his sons Alan and Mark (right). (Photographs courtesy of the Klatsky family.).TRAINING After graduating from the University of Maryland School of Medicine in 1962, Stanley interned at Mt. Sinai Hospital in Baltimore, where he completed a general surgery residency. Considering a career in cardiac surgery or neurosurgery, he volunteered for a clinical clerkship in open heart surgery at Walter Reed Hospital. At that time, the cardiac and plastic surgery operating rooms shared a common break room, where he was first exposed to plastic surgery. It did not take him long to realize one of the key differences between plastic surgery patients and those on the cardiac service: the former almost always ended up alive and happy. He decided that plastic surgery was, in fact, his calling. Columbia Presbyterian Hospital in New York was where Stanley served his plastic surgery residency. It was one of the premier plastic surgery training programs at the time. He began his training in 1966 under the directorship of Dr. George Crikelair. Given his background in general surgery, Stanley initially was interested in reconstructive surgery, especially head and neck cancer. Crikelair was a plastic surgeon who “operated on everything from the top of the head to the bottom of the feet” (Klatsky), and his special interest in children’s burns is credited with saving many lives. Although he was introduced to aesthetic surgery during his training in New York, such surgery was not well acknowledged in academic plastic surgery circles. EARLY CAREER After finishing his residency in 1968, Dr. Klatsky moved back to Baltimore to begin private practice and affiliated as part-time staff at Johns Hopkins under the direction of Milton Edgerton, M.D. He was the ninth plastic surgeon in the Baltimore community. One of his mentors from Columbia Presbyterian, Dr. Jerome Webster, warned: “Now just remember, son, when you go down there to the school of Halsted, you’ll be the new ballplayer. Just make sure you get on first base and don’t go for the long ball.” In Baltimore, he began to concentrate on aesthetic surgery. Stanley didn’t just get on first base; he became a “World Series Champion” in aesthetic surgery. Dr. Klatsky was a respected member of the community of plastic surgery. In the 1970s, Dr. Klatsky with Dr. Hoffman pioneered in Maryland the use of the “all-in-one mastectomy and immediate reconstruction technique,” all done at the time of the mastectomy, published in 1985. He was a founding member of the John Staige Davis Society of Plastic Surgeons of the State of Maryland in the 1960s, and served as its president in 1981. He was also a founding member of the New England Society of Plastic Surgeons and went on to numerous officer and representative positions on the New England Society of Plastic Surgeons, American Society of Plastic and Reconstructive Surgeons, American College of Surgeons, and the Plastic Surgery Educational Foundation. He was chief of staff at Northwest Hospital Center (Fig. 3).Fig. 3.: Stanley Klatsky lecturing on aesthetic surgery at Northwest Hospital in Maryland.THE AESTHETIC SOCIETY Stanley was involved at the very inception of the American Society for Aesthetic Plastic Surgery. He attended the first organizational meeting in New Orleans that would eventually lead to the formation of the American Society for Aesthetic Plastic Surgery in 1968. He was elected by the board of directors as the new candidate representative, held innumerable positions in the Society, and became president in 1986. He was very committed to maintaining a record of the history of American Society for Aesthetic Plastic Surgery and led the project “35 Years and Counting”—the American Society for Aesthetic Plastic Surgery retrospective featuring interviews of its presidents. He was consistently devoted to mentoring others, and both initiated and fostered many collaborative international relationships. He was cited as one of the World’s Distinguished Aesthetic Surgeons, and received the American Society for Aesthetic Plastic Surgery Distinguished Service Award in 2001. “He maintained a ‘DiMaggio-like’ attendance record at American Society for Aesthetic Plastic Surgery meetings and symposia for just short of 50 years” (D. Morello). He was instrumental in establishing criteria for safety and credentialing in the operating rooms through the American Association for Accreditation of Ambulatory Surgery Facilities. AESTHETIC SURGERY JOURNAL Stanley had a remarkable impact on the development of the Aesthetic Surgery Journal, serving as Editor-in-Chief from 1998 to 2008. At the time he became Editor, the journal was published six times per year and divided into two sections: clinical articles and peer-reviewed scientific articles. Stanley devoted himself to publishing 12 excellent issues per year. Notably, it was not indexed by the National Library of Medicine, a goal to which Stanley dedicated himself over the course of his 10 years, finally achieving success on the eve of his retirement as Editor in 2008.Those who knew and collaborated with Stanley Klatsky remember him: One of the aspects that stood out when interacting with Stanley and his wife Rosalie at the [American Society for Aesthetic Plastic Surgery] meetings was his pride in his appearance. He always looked professional and radiated a willingness to serve as a mentor to those around him—Board members, new applicants, residents. He was quite the raconteur and never at a loss for words. Stanley would regale those around him with tales of the early days of the Aesthetic Society. —Robert Singer In reflecting back on the many years during which Stanley Klatsky served as a mentor and sounding board to me as well as to other senior plastic surgeons, I think of all that he did for many of us. I would always look forward to joining him for lunch or dinner, whether at a meeting or visiting with him in Baltimore or elsewhere. I knew some good stories awaited, their cadence and details in the telling, pitch perfect. The stories were frequently in response to some question I or someone else would ask, the answers drawn from some personal work or life experience. I know, too, that he enjoyed their recounting as much as I and others relished hearing them. I can’t begin to enumerate the lessons I learned from these moments. He didn’t dwell on his own past accomplishments. I think, perhaps, what lay behind him was far less important to him than that what lay ahead. And on that subject, he was more than happy to share his thoughts. —Bob Bernard Stanley loved the meetings and parties. He immensely enjoyed the camaraderie and laughter with the good friends and extended family in his chosen field. He could always be found on the dance floor or huddled in the corner enthusiastically talking “business.” —Robert Singer Stanley Klatsky succeeded me (Dr. Bernard) as editor of Aesthetic Surgery Journal [italics added]. As can happen from time to time in any volunteer organization, certain individuals will gladly accept the “title,” but not so much the necessary responsibilities and work that come with the title. Stanley was quite the opposite. He dove right into the task and worked tirelessly, making a Herculean effort to achieve indexing by the National Library of Medicine. Interestingly, after [10] years, indexing was awarded near the last day of Stanley’s tenure as Editor-in-Chief. —Bob Bernard JOHNS HOPKINS Throughout his career, Dr. Klatsky maintained a strong connection with the Department of Plastic and Reconstructive Surgery, initially at Johns Hopkins and after 1988 through years of association with the Johns Hopkins/University of Maryland Plastic Surgery program. He personally contributed much to resident aesthetic education in that residency, and also created a series of educational videos with Dr. Paul Manson that are available today for all trainees at Johns Hopkins. He enjoyed lecturing and was very adept at it, and was a consistently loyal faculty member. The program continues to honor Dr. Klatsky through a quarterly lectureship, the “Stanley A. Klatsky, M.D. Business of Health Care Lectureship,” an incredibly important part of resident education that will continue for the years to come. These reflections and those of others will not be long remembered. But Stanley Klatsky’s contributions on behalf of the Aesthetic Society, the Aesthetic Surgery Journal [italics added], the History of the Aesthetic Society and [American Association for Accreditation of Ambulatory Surgery Facilities] will continue to positively impact generations of plastic surgeons. —Robert Singer and Bob Bernard

Hopkins reunion

For many people, the term “robotic surgery” likely evokes one of two images. One is Asimo, the Honda robot, performing a complex heart-valve replacement with the precision and finesse of the most skilled surgeon. The other is more along the lines of an industrial robot found welding on an automotive assembly line—performing surgery by rote programming on scores of patients in a row, just like in a factory. Neither is the case. Robotic surgery is, by some accounts, the next level of minimally invasive surgery.Conventional invasive surgery involves a large incision in the body to gain access to the area and organ of interest. For example, in a conventional gallbladder removal, the surgeon first performs a laparotomy, which is an incision, usually a large one, through the abdominal wall to gain access to the interior of the torso. The problem with a laparotomy is that it is very stressful physiologically and exposes large portions of the patient's abdominal cavity to infection. Additionally, because the incision is so large, and the surgeon needs access to a large part of the patient's interior, the surgery is characterized by a relatively large amount of trauma to the surrounding tissue, blood loss, and postoperative pain and discomfort coupled with a prolonged healing period. To overcome the problems and side effects of the laparotomy, minimally invasive surgery was developed.Minimally invasive surgery accesses the chest or abdomen through several smaller incisions, each one typically half an inch long. Each smaller incision has a port, or a combination trocar/port is used to make the incision, to protect the surrounding tissue while a particular device is inserted through the hole. The most common items inserted are an endoscope connected to a camera, a light source (which may be part of the other devices), an insufflator, and an instrument with one or more operating channels. In the case of minimally invasive gallbladder removal, now called a laparoscopic cholecystectomy, all the associated steps (draining the gall bladder, severing it from the ducts, and removing the empty bladder) are performed through the operating channel using specially adapted instruments. In minimally invasive surgery, as few as three or four small incisions can take the place of the much larger laparotomy incision. Some surgeons also perform this procedure as “scarless surgery” by accessing the abdomen through the navel and using a specialized operating endoscope with integral illumination and operating channels. Although there technically is a scar, observers might be hard pressed to find it as it is hidden in the folds of the navel. As one would expect, the smaller incisions mean less trauma to the body as a whole, reduced blood loss, and minimal discomfort, all of which equate to a shorter healing period.Minimally invasive surgery techniques are primarily responsible for the increase in “same day surgery” procedures. Cases employing laparatomies frequently required a one to two week hospital stay for observation (in the event of complications like hemorrhage) and recuperation. Now that time is reduced to a few hours of post-recovery room rest, and patients are discharged later that same day to finish their recuperation at home.As good as minimally invasive surgery is, it also has some drawbacks. Because the space inside the torso is very limited, and the operation is performed with a minimum of disturbance to the surrounding tissue, it can be difficult for the surgeon to visualize the surgical field and manipulate the instruments. In such a small space, minute but precise movements of the instruments are required to ensure the operation remains trouble free. Poor visibility in the surgical field has led to problems ranging from accidentally nicking adjacent tissue to more serious matters, such as cutting a liver duct in addition to the bile duct or accidentally severing an artery beyond the surgeon's field of view. Robotic surgery systems are designed to overcome these challenges and provide yet another major advancement in surgery. To date, robotic surgery systems are viewed warily in many healthcare facilities, partially due to their high cost—$1.25 million and up—and to the limited types of procedures they may perform. Despite these obstacles, facilities in 2012 performed approximately 450,000 robotic surgical procedures in more than 2,000 facilities worldwide.Robotic surgery systems are expensive, and they are approved by the U.S. Food and Drug Administration (FDA) for only a handful of procedures in cardiac, gynecology, otolaryngology, pediatric, and urology specialties. Second, as of this writing, there are only three models of systems approved for sale and use in the United States, and all of them are made by a single company. Their high price and relatively limited number of approved applications makes them impractical for many small rural medical facilities. They are found more often at tertiary referral facilities, where the necessary specialists and case workload supports their utilization. Because there is only a single manufacturer, much of the information on the three models is considered proprietary. However, some interesting information about them is available if one digs deep enough.All three robotic surgery systems employ a physician's console with computerized controls and a patient side cart containing up to four instrument arms, including an endoscope connected to a fiber optic camera. The surgeon's console is located within several yards of the operating table and patient side cart. Unlike traditional endoscopic viewing, with robotic systems, the surgeon sits and looks into a large hooded viewing area. The hood blocks outside light and facilitates concentration. The high-resolution video monitors inside the hood provide the surgeon a stereo image magnified tenfold of the operating site from the endoscope mounted on the patient side cart. This video system places the surgeon inside the patient looking at the surgical site from only a few millimeters away, with the instruments and images directly in front of the surgeon, between his or her arms. Even current minimally invasive surgery requires the surgeon to look up and away from the patient and his instruments to view the surgical site on a monitor mounted near the operating table. Some surgeons believe that this view is superior to that provided by even conventional surgery. At the surgeon's left and right hands are joystick-like controls with additional controls mounted at his feet. A “bumper” device in the hand controls provides tactile feedback when using certain tissue grasping instruments. Armrests help to minimize fatigue during the operation. The hand and foot controls manipulate the operating instruments attached to the patient side cart. Additionally, the surgeon is capable of zooming in to obtain a better view of details at the surgical site.The computer forms the interface for the surgeon's hand and foot movements and translates those into movements of the instruments attached to the patient side cart. Two important characteristics of the software is that it controls the zoom of the video and reduces the surgeon's movements to compensate for the magnified view of the surgical field. Lastly, the computer buffers the surgeon's movements to compensate for any minor tremors and provides positive feedback to the bumpers when grasping something.The patient side cart replaces the table-side surgeon and looks like a cross between a praying mantis and the multiarmed Hindu goddess Kali. The cart contains as many as four arms, folded like the forelegs of a praying mantis when retracted to the parked position, arrayed across its top to allow full movement of each arm in all planes. Each arm is capable of holding one of the specially designed or adapted operating instruments—a miniaturized surgical camera, wristed scissors, scalpels, forceps—all designed to help with delicate dissection and reconstruction deep inside the body. As the operation progresses, the instruments are changed by the secondary surgeon or by a trained operating room nurse or technician as required.Maintenance services should be scheduled and tracked uniquely for each system with equal consideration given to liability, the initial cost, and the proprietary nature of the hardware and software. Each system should have a detailed maintenance history. Owing to both the uniqueness and proprietary components of robotic surgery systems, a maintenance contract with the manufacturer is recommended. As competitive products enter the field of robotic surgery, options other than full-service contracts may be viable in the future. With manufacturer training, a first-call contract would be the best mix of in-house and contractor maintenance capabilities.There are no specific regulations covering robotic surgery systems. As always, it is crucial to follow regulations promulgated by the FDA.There have been reported equipment malfunctions in robotic surgery systems that impact the risk manager. Malfunctions of the arms, console, the optics, the computer, or any of the instruments during an operation can result in disaster for the patient. The FDA's Manufacturer and User Facility Device Experience (MAUDE) database contains a number of incident reports and complaints about these systems. In 2012, there were 282 adverse event reports associated with these systems at more than 2,000 hospitals. Before allowing surgeons to use robotic surgery systems, hospitals typically require many hours of simulator training, akin to requiring flight simulator and actual flying hours prior to awarding a pilot's rating. Aside from the few computer-related hardware problems, most of the risk management issues associated with these systems are totally in the surgeon's hands. Although tremor-like movements are filtered out, gross unintended hand movements are replicated by the system, which could result in a surgical error. Postoperative infection is always a concern with any invasive procedure, and robotic surgery is no exception. Although the surgery site or sites are smaller, infection either at the point of intrusion or deep within the torso is still a possibility.The most common problems reported with these systems are blown fuses, damaged cannulae, system “lockups,” and operational failure due to software issues. The first two can be can be resolved by in-house biomeds and nursing staff. Rebooting the system can resolve a software lockup, but this can be problematic if a computer lockup occurs repeatedly, especially during a case. Since contract maintenance is recommended, in-house biomeds will rarely if ever be called in to troubleshoot a problem.At this time, no additional training or equipment is necessary to service robotic surgery systems. Because there is only one manufacturer of this product, contract maintenance is the only sensible way to service these systems. As more manufacturers enter the field of robotic surgery, it's possible that service options could well include something other than a full-service contract. When this occurs, a first-call maintenance contract is the method of choice provided manufacturer training is available. Unlike a typical first-call maintenance agreement, such a contract also should cover software and firmware updates. Additionally, it should contain negotiated prices for system upgrades and other options when needed. Although current system designs are proprietary to the sole manufacturer of robotic surgery systems, future systems may employ, in addition to their computer and electronics components, principles of fluidic and vacuum systems to manipulate the arms, hands, and instruments. Biomeds servicing this equipment must be familiar with these systems and generally well versed in all disciplines of biomedical equipment maintenance.While there is only one manufacturer marketing robotic surgery systems in the United States, more are sure to follow. At this time, the field is wide open for improvements. For example, one system currently under development promises to provide both visible light and ultrasound images of the surgical site. This feature will allow the surgeon to see not only the surface, but also the internal structure of the tissue. Another area needing further development is that of tactile feedback. Current units only provide a vibrating indicator of the pressure being exerted. Future instruments may well provide real-time, pressure-proportionate tactile feedback to the surgeon.

CORR Insights®: Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes.

C. James Carrico, MD