American Surgeons Research Articles

Current technique of laparoscopic total mesorectal excision (TME): an international questionnaire among 368 surgeons

Current literature shows no consensus for the technique of laparoscopic total mesorectal excision (LTME). This study aimed to assess the current practice of LTME. From January to March 2008, members of the European Association for Endoscopic Surgery (EAES), the Indian Association of Gastrointestinal Endo-Surgeons (IAGES), and the Society of Laparoscopic Surgeons (SLS), together with renowned surgeons in the field of LTME, were invited to fill out an online questionnaire concerning aspects of LTME. The 368 questionnaires showed that 77% of the study participants performed 1-20 LTMEs per year (low volume) and that 33% performed more than 20 LTMEs per year (high volume). Preoperative bowel preparation (PBP), Trendelenburg position, periumbilical insertion of a 30º laparoscope, medial-to-lateral dissection, ultrasonic hemostasis, high-tie ligation, splenic flexure mobilization, left ureteral identification, partial sigmoid resection, extraction of the specimen by a new minilaparotomy and wound protector, end-to-end stapled anastomosis using a 28- to 29-mm anvil with 3.5-mm staples, abdominal lavage, pelvic drainage, and diverting ileostoma were performed by a majority of the surgeons. Less consistency was observed in identification of the right ureter, dissection of Denonvilliers' fascia, location of the minilaparotomy, and construction of a colonic pouch. There were significant differences between high and low volume and between American and European surgeons. Significantly more low-volume surgeons indicated a preference for an open TME depending on the age and gender of the patient, the presence of comorbidity, previous laparotomy, and locally advanced tumor. More low-volume surgeons applied PBP (83.4% vs. 71.8%; p = 0.017). On the average, high-volume surgeons identified more autonomic pelvic nerves during dissection (2.6 vs. 1.8 nerves). The right ureter was identified by 66% of the American and 31.2% of the European surgeons. In the United States 91.5% and in Europe 61.2% created an end-to-end anastomosis. Pouches were created by 32% of the European and 6.8% of the American surgeons. The respondents showed an apparent preference for several aspects of LTME. Differences were related to expertise and still more to continent.

Reconstruction of the Maxilla with Prefabricated Scapular Flaps in Noma Patients

Sir: We read with great interest the article entitled “Reconstruction of the Maxilla with Prefabricated Scapular Flaps in Noma Patients” by Vinzenz et al. (Plast Reconstr Surg. 2008;121:1964-1973), and we wanted to point out that although motivated by genuine humanitarian concerns, such projects may serve to promote “noma tourism” rather than significant improvements in the local medical infrastructure. Noma reconstructive surgery has become a challenge for plastic surgeons in the industrialized West; noma continues to afflict sub-Saharan countries as a community disaster. As awareness of this problem has become more widespread, increasing numbers of American and European surgeons are volunteering to go on short-term medical mission trips to perform repair operations in African countries or to organize transfer of patients to the industrialized countries. Why present a program with no chance of being performed locally and that implies enormous funding that could be used to promote local health programs? Accurate data collection, thoughtful study design, critical ethical oversight, logistical and financial support systems, and the nurturing of local capacity should be emphasized. The most critical elements in the development of successful programs for treating noma patients are a commitment to developing holistic approaches that meet the multifaceted needs of the noma victim and identifying and supporting local correspondents who can provide long-term success for such programs. In complete opposition to the strategies presented in the article by Vinzenz et al., the senior author has developed a large program of cooperation over the past 12 years regarding noma in Niger (Operation Sourire Medecins du Monde), including three surgical missions per year and acceptance of four Niger plastic surgeons in our fellowship program. More than 70 noma patients were treated locally.1 Our strategy was to develop effective surgical techniques that could be performed locally by local surgeons with funding by the nongovernmental organization. We present the case of a 12-year-old boy who was infected with human immunodeficiency virus and who developed noma during his early childhood. After the beginning of a classic World Health Organization anti–human immunodeficiency virus therapy and a complete nutrition program, we had to reconstruct these complex noma sequelae (Fig. 1). Reconstruction was performed by means of a single-pedicle latissimus dorsi flap with four skin paddles in a first mission to Niger in November of 2006. The flap was able to reach the cheek because of a cervical inverted Z-plasty with the aim of shortening the cervical area (Fig. 2). At the same time, a frontal flap was used to reconstruct the nasal rim. Three months later, in a second mission, a local Estlander flap and complete remodeling of the latissimus dorsi flap was performed. The result was achieved in only two missions with soft-tissue neosegmentation (Fig. 3), giving the patient a chance of socialization and the local surgeon a chance of performing such operations on his own one day.Fig. 1.: Preoperative view.Fig. 2.: After the first step: pedicle latissimus dorsi with inverted cervical Z-plasty.Fig. 3.: After the second step: modeling of the latissimus dorsi, Estlander flap, and frontal flap to reconstruct the nasal rim.The codes of conduct2,3 of nongovernmental organizations clearly stipulate in Article 6 that we shall attempt to build disaster response on local capacities and in Article 7 that ways shall be found to involve program beneficiaries in the management. The principle of “responsibility”4 must remain in the ethical guidelines for these humanitarian programs. The responsibility in this case is to build for the local surgeons a chance to solve local problems. Alain M. Danino, M.D., Ph.D. Service de Chirurgie Plastique Centre Hospitalier de l’Université de Montréal Hôpital Notre Dame Montréal, Quebec, Canada Jean Marie Servant, M.D. Service de Chirurgie Plastique Hopital Saint Louis Université de Paris Paris, France

Femoral Neck Fractures: Evidence Versus Beliefs About Predictors of Outcome

It is unclear whether current practice reflects current evidence on predictors of clinically important outcomes like mortality and fixation failure. Knowledge of predictors of outcome can and should influence treatment decisions and can subsequently improve outcomes. We hypothesized that there is evidence about the significance of predictors of outcome not being considered in the decision making process in the treatment of hip fractures because many surgeons are unaware of it. We surveyed 298 North American and European orthopedic surgeons to examine their training and experience and their opinion on the relative importance of predictors of outcome of femoral neck fracture treatment. We compared the results with the highest level of therapeutic and prognostic evidence currently available. Surgeons' perceptions about the importance of the quality of fracture reduction, patient comorbidities, degree of fracture displacement, dementia, and prefracture walking ability were justified by the current literature. However, we further identified a number of variables deemed unimportant to surgeons that have evidence to support their use in managing patients with hip fractures, including the type of anesthesia as a modifiable variable. In contrast to surgeons' perceptions, the available evidence suggests regional anesthesia is associated with a lower mortality risk than general anesthesia.

Mohs Micrographic Surgery

The Mohs micrographic surgical technique was first described by Frederick Mohs, an American surgeon, in 1941[1]. He introduced a new method for the removal of skin cancer, in which the tumour is re...

Bone Tissue Engineering, the New Concept in Regenerative Medicine and Surgery

From the Tampa Bay Craniofacial Center, Tampa, Florida. Address correspondence and reprint requests to Mutaz B. Habal, MD, FRCS, FACS, Tampa Bay Craniofacial Center, Tampa, FL; E-mail: [email protected] Based in part on a keynote lecture at the XI Congress of Italian and American Plastic Surgeons, Bologna, Italy, June 2008.

Lessons from the past: pathways to the future

A famous American surgeon, A. Bruce Gill, once said “Study principles, not methods. A mind that understands principles can devise its own methods.” Here I discuss 10 basic principles in the field of spinal deformity treatment that have strong messages from the past and apply equally to the future. Principle 1: Progressive curves must be stopped by bracing or surgery — there is no excuse for procrastination That spinal curves must be stopped from progressing by bracing or surgery is a very old principle, and we should not even have to mention it in this era, but the problem still exists. Sometimes the problem lies with the general practitioner who does not understand the seriousness of a child with a unilateral unsegmented bar and fails to refer the child promptly to a spine specialist. Only when the curve has progressed severely does the referral come, and then it is too late. This is a problem of educating our medical colleagues. Sometimes the problem is with the spine surgeon who either fails to recognize the serious nature of the problem or fails to measure the films carefully to detect the progression. Sometimes there is simply a reluctance to operate on a 1-year-old child for fear of “stunting the child’s growth.” Letting a curve progress severely gives far more torso shortening than would early fusion.

Can patients help with long-term total knee arthroplasty surveillance? Comparison of the American Knee Society Score self-report and surgeon assessment

To compare patient self-report of knee flexion, extension, range of motion (ROM) and American Knee Society (AKS) Pain, Knee and Functional scores with a clinician assessment. A total of 239 consecutive total knee arthroplasty (TKA) patients (290 knees) were mailed surveys with an AKS questionnaire and lateral knee photographs that showed knee ROM in 10 degrees increments to compare their operated knee(s) ROM. Patients were subsequently seen in clinic and their ROM, AKS Pain, Knee and Functional scores were measured. Patient- and physician-reported measures were compared using independent sample t-test and correlated using Spearman's correlation coefficient. A priori rules for comparisons were based on previously published reports. A total of 286 knees had both survey and clinic data available and constituted the analytic set. Patient-reported and physician-assessed extension, flexion and ROM were: 3 +/- 4.8 degrees vs 1.4 +/- 4.3 degrees (P < 0.001), 111.4 +/- 14.6 degrees vs 110 +/- 12.8 degrees (P = 0.04) and 108.6 +/- 16.8 vs 108.6 +/- 14.3 degrees (P = 0.98). There was a moderate correlation between patient and physician assessments (extension = 0.31; flexion = 0.44; ROM = 0.42; P < or = 0.001 for all). Patient-reported and physician-assessed AKS Pain, Knee and Functional scores were: 35.8 +/- 15.6 vs 43.9 +/- 11.1 (P < 0.001), 79.8 +/- 20 vs 88.9 +/- 13.3 (P < 0.001) and 57.7 +/- 23.1 vs 65.7 +/- 26.4 (P < 0.001), respectively. Patient- and physician-assessed AKS Pain, Knee and Functional scores had moderate-high correlation (r = 0.49, 0.49 and 0.70; P < or = 0.001 for all). Long-term surveillance of TKA patients may be possible using a self-report AKS, but the average 8- to 10-point difference between patient- and physician-reported AKS scores (patients reporting poorer scores) represents a substantial impact on this outcome instrument. Since patient-reported responses have clear value in global assessment, further evaluation with other validated outcome instruments is warranted.

Results of a National Survey of Surgical Resident Interest in International Experience, Electives, and Volunteerism

Data are emerging about the essential nature of sustainable global surgical care and interest among North American surgeons. Currently, there is no formal mechanism for US surgical residents to participate in international training opportunities. A small, single-institution survey found that general surgery residents at New York University are highly motivated to pursue international training. But little research has addressed the attitudes of North American residents about international training. The goal of this study was to acquire a broader understanding of surgical resident interest in international training. A structured questionnaire was administered anonymously and voluntarily to all American College of Surgeons resident members. Seven hundred twenty-four residents completed surveys. Ninety-four percent of respondents planned careers in general surgery. Ninety-two percent of respondents were interested in an international elective, and 82% would prioritize the experience over all or some other electives. Fifty-four percent and 73% of respondents would be willing to use vacation and participate even if cases were not counted for graduation requirements, respectively. Educational indebtedness was high among respondents (50% of respondents carried >or=$100,000 debt). Despite debt, 85% of respondents plan to volunteer while in practice. The most frequent barriers identified by respondents were financial (61%) and logistic (66%). American College of Surgeons resident members are highly motivated to acquire international training experience, with many planning to volunteer in the future. A consensus among stakeholders in North American surgical education is needed to further explore international training within surgical residency.

IPEG Guidelines for Surgical Treatment of Extremely Obese Adolescents

Journal of Laparoendoscopic & Advanced Surgical TechniquesVol. 18, No. 6 IPEG Guidelines for Surgical Treatment of Extremely Obese AdolescentsPublished Online:23 Dec 2008https://doi.org/10.1089/lap.2008.9987AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byBariatric surgery in the treatment of adolescent obesity: current perspectives in the United States21 April 2021 | Expert Review of Endocrinology & Metabolism, Vol. 16, No. 3Adolescent bariatric surgery3 March 2012 | Abdominal Radiology, Vol. 37, No. 5Revisiting Childhood Obesity: Persistent Underutilization of Surgical Intervention?1 July 2012 | The American Surgeon, Vol. 78, No. 7The role of parents in pre-adolescent and adolescent overweight and obesity treatment: a systematic review of clinical recommendations27 April 2011 | Obesity Reviews, Vol. 12, No. 10Bariatric surgery in young massively obese diabetic patientsDiabetes & Metabolism, Vol. 35, No. 6Pediatric Nonalcoholic Fatty Liver Disease in 2009The Journal of Pediatrics, Vol. 155, No. 4Pharmacotherapy and Surgery Treatment for the Severely Obese AdolescentJournal of Pediatric Health Care, Vol. 23, No. 4 Volume 18Issue 6Dec 2008 Information© 2008 Mary Ann Liebert, Inc.To cite this article:IPEG Guidelines for Surgical Treatment of Extremely Obese Adolescents.Journal of Laparoendoscopic & Advanced Surgical Techniques.Dec 2008.xiv-xvi.http://doi.org/10.1089/lap.2008.9987Published in Volume: 18 Issue 6: December 23, 2008PDF download

Letters to the Editor

Statements appearing here are those of the writers and do not represent the official position of THE AMERICAN SURGEON. Comments on any topic are invited; those accepted for publication will not be subject to major editorial revision but generally must be no more than 500 words in length. The editor reserves the right to publish replies and may solicit responses from authors and others.

Hormone therapy: a revolution in understanding prostate cancer

Until the middle of the 20th century, little knowledge of the behaviour of prostate cancer existed and awareness of its exquisite sensitivity to hormones had not been realised. The conventional understanding was that prostate cancer was an autonomous, self-perpetuating, and fatal malignant disease, the progression of which could not be changed by external manipulation. In 1941, Charles Brenton Huggins, a Canadian-born American surgeon, revolutionised our understanding of prostate cancer and irrevocably changed the approach of physicians in managing and researching the treatment of neoplastic disease in general. His pioneering work heralded the era of rational drug therapy for all cancers and earned Huggins the Nobel Prize in Physiology and Medicine in 1966. Charles Huggins graduated from Harvard Medical School (Boston, MA, USA) in 1924. In 1927, he was appointed to the surgical faculty at the University of Chicago (Chicago, IL, USA) where he became Professor of Surgery in 1936. Subsequently, in 1966, he became the second surgeon to win a Nobel Prize in Medicine, with a comment from the Nobel Committee proclaiming Huggins’ work had “already given many years of an active and useful life to patients with advanced cancer over the entire civilized world—patients who would have been lost to other forms of therapy”. Many have suggested that his ground-breaking discoveries, fi rst published in 1941, should have been acknowledged by the committee at a much earlier date. In the original study by Huggins and Hodges (his student), eight patients with metastatic disease to bone were selected from an initial group of 47 patients with prostate cancer. All eight patients underwent bilateral orchidectomy; however, before this procedure, fi ve were started on daily injections of stilboestrol or oestradiol benzoate, and three were injected with daily testosterone propionate. Serum acid-phosphatase concentrations decreased in patients who received oestrogen injection before the procedure and increased in those who received testosterone propionate. From these fi ndings, Huggins and Hodges concluded that prostate cancer was receptive to androgenic activity in the body and that metastatic prostate cancer was inhibited by eliminating circulating androgens—either by surgical orchidectomy or by administration of oestrogens. Moreover, they also showed that prostate cancer was activated by androgen injections. These fi ndings have provided the scientifi c basis for the contemporary treatment of prostate cancer. For nearly 30 years after this seminal report by Huggins and Hodges, patients with advanced prostatic carcinoma were managed either by surgical orchidectomy or oestrogens, until it was shown that treatment with oestrogens resulted in substantial thromboembolic and cardiovascular complications. This fi nding stimulated further research into alternative hormonal treatments, which culminated in the development of various antiandrogens (eg, cyproterone acetate and fl utamide) and most notably synthetic luteinising-hormonereleasing-hormone (LHRH) agonists in the 1970s. The therapeutic eff ectiveness of LHRH in achieving medical castration has yet to be surpassed. Although these hormonal treatments were originally used to manage patients with metastatic disease, androgen ablation therapy is now used in a neoadjuvant or adjuvant setting in combination with surgery or radiation in patients with locally advanced disease only or in those with biochemical relapse after radical treatment for localised disease. The epic work by Huggins and Hodges will remain a cornerstone in the annals of medical literature because it initiated the use of endocrine therapy in the management of disseminated prostate cancer and showed that the course of neoplastic disease could be changed by rational external intervention. One can state with certainty that there are few articles in science, which have had, or will have, such a lasting impact.

Letters to the Editor

Statements appearing here are those of the writers and do not represent the official position of THE AMERICAN SURGEON. Comments on any topic are invited; those accepted for publication will not be subject to major editorial revision but generally must be no more than 500 words in length. The editor reserves the right to publish replies and may solicit responses from authors and others.

Practice Profiles in Breast Reduction: A Survey Among Canadian Plastic Surgeons

Breast reduction is an increasingly common procedure performed by Canadian plastic surgeons. Recent studies in the United States show that use of the inferior/central pedicle inverted T scar method is predominant. However, it is unknown what the practice preferences are among Canadian plastic surgeons. The goal of the present study was to assess trends in breast reduction surgery among Canadian surgeons, including patient selection criteria, surgical techniques and outcomes. Surveys were distributed to plastic surgeons at the Canadian Society for Plastic Surgery meetings in 2005 and 2006. Completed surveys were obtained from 140 respondents, and results were analyzed with Excel and SAS software. There was a 40% response rate. The majority of surgeons (66%) used more than one technique for breast reduction. Most commonly, surgeons use the inverted T scar technique (66%) followed by vertical scar techniques (26%). The most popular vertical scar techniques included the Hall-Findlay (14%) and Lejour (13%) methods. Most surgeons (55%) reported complication rates of less than 5% and the most common complication reported was wound dehiscence. There was no difference in overall complication rates between inverted T scar and vertical scar surgeries. The majority of surgeons (98%) carried out breast reduction either exclusively as day surgery or in combination with same-day admission. Breast reduction performed as day surgery resulted in cost savings of $873 per patient. Canadian plastic surgeons are performing more vertical scar breast reductions than American surgeons. However, both groups rely predominantly on inverted T scar techniques.

Letters/Editorial

Letters/Editorial

Lymph Node Analysis in Esophageal Resection: American College of Surgeons Oncology Group Z0060 Trial

The American Joint Committee on Cancer staging of esophageal cancer has been criticized for not establishing a minimum standard for lymphadenectomy, and for relying on location of nodes involved rather than their number. The objective of this study was to review the current practice of American surgeons with regard to lymph node assessment during esophageal resection. The operative and pathology reports of patients who underwent staging by computed tomography and fluorodeoxyglucose-positron emission tomography and subsequent resection for esophageal cancer (multiinstitutional American College of Surgeons Oncology Group Z0060 trial) were analyzed. One hundred forty-five patients underwent resection. Operative and pathology reports were unavailable in 11 patients. The results of the remaining 134 resections (Ivor-Lewis, n = 64; transhiatal, n = 59; other, n = 11) were reviewed. Overall, 13 +/- 9 (mean +/- standard deviation) lymph nodes were evaluated per patient. More lymph nodes were evaluated in patients undergoing Ivor-Lewis (15 +/- 9) than transhiatal esophagectomy (9 +/- 7; p < 0.001). The mean number of distinct lymph node stations analyzed per patient was 3 +/- 2. In 38% (51 of 134) of patients the nodes attached to the specimen were evaluated without any distinction among nodal stations. The practice of submitting named packets of nodal material resulted in 16 +/- 9 nodes per case, as opposed to the practice of submitting an entire specimen for the pathologists to dissect, which yielded 10 +/- 8 nodes (p < 0.001). There is considerable variability and room to improve in the extent of resection and pathologic evaluation of esophagectomy specimens. A uniform standard for esophageal cancer resection is warranted to improve the precision and value of pathologic staging.

SAGES 2007 rural surgery panel

Rural surgery: 59 million rural American citizens (2000 Census). Who cares? In 1999, SAGES President L. William Traverso articulated the importance of rural surgery and created the rural surgery task force. During the 2007 SAGES annual meeting in Las Vegas, the rural surgery task force, now turned into the rural surgery liaison group, presented a panel discussion that examined rural surgery manpower demographics, SAGES’ relationship with the rural surgeon, the American College of Surgeons’ advisory council for general surgery subcommittee on rural surgery, the challenges facing the practising rural surgeon, rural surgery contributions to medical education, and the education of the rural surgeon. It was the first SAGES public forum on rural surgery, and it may possibly be its last. In recent years, the SAGES rural surgery liaison group has conducted three internet surveys to understand the practice circumstances and needs of its rural members. In addition, SAGES’ rural surgery liaison group members made rural surgery presentations at the American College of Surgeons Washington/Oregon and Oklahoma 2006 chapter meetings and the Mithoefer Center for Rural Surgery second annual rural surgery symposium in Cooperstown, NY in September 2006. Members of the SAGES rural surgery liaison group also independently studied the use of endoscopy and laparoscopy in Wyoming, Montana, and Oklahoma. Here is what we know. Rural surgeons perform more procedures than their urban counterparts, nearly double the laparoscopic procedures and triple the number of endoscopies [1]. From the SAGES rural surgery surveys, we find that the nearest gastroenterologist is more than 20 miles distant in 50% of rural surgery practice situations. For screening colonoscopy, the rural general surgeon is the physician of first choice in 65% of rural surgery environments and second choice in 32%. Two-thirds of rural surgeons received their flexible endoscopy training during residency, and this trend will surely increase as the accreditation council for graduate medical education (ACGME) minimum-defined category numbers for endoscopy continue to increase. Only 42% of SAGES rural surgery members attend a SAGES meeting once every 5 years, and unfortunately 26% never attend a SAGES meeting. The most common (45%) referral population for a rural general surgeon is 0–25,000 people. The nearest tertiary hospital is C50 miles in 69% of rural surgery practices. At least two-thirds of SAGES rural surgeons take advantage of SAGES benefits (practice guidelines, privileging guidelines, or outcome case logs in conjunction with the American College of Surgeons). Three-quarters of rural surgeons are not interested in a PAC, but would like to see rural surgery better represented in the hierarchy of national surgical societies. We have significant gaps in our knowledge of rural surgery. Who is the rural surgeon: even a frontier surgeon? Rural surgeons have been defined by population [2] and rural–urban commuting codes [3]. Perhaps hospital size, numbers, and specialities of local supporting physicians, Health Professional Shortage Areas (HPSAs) as defined by the Department of Health and Human Services Health Resources and Services Administration for federal grants eligibility, specialty Physician Scarcity Areas (PSAs) created by the Centers for Medicare and Medicaid Services (CMS) for 5% physician bonus payments, and access to a skilled health care workforce would be equally important Presented at the Annual Meeting of the Society of American, Gastrointestinal and Endoscopic Surgeons (SAGES), Las Vegas, Nevada, USA, April 18, 2007.

Treatment of achalasia: lessons learned with Chagas’ disease

Chagas' disease (CD) is highly prevalent in South America. Brazilian surgeons and gastroenterologists gained valuable experience in the treatment of CD esophagopathy (chagasic achalasia) due to the high number of cases treated. The authors reviewed the lessons learned with the treatment of achalasia by different centers experienced in the treatment of Chagas' disease. Preoperative evaluation, endoscopic treatment (forceful dilatation and botulinum toxin injection), Heller's myotomy, esophagectomy, conservative techniques other than myotomy, and reoperations are discussed in the light of personal experiences and review of International and Brazilian literature. Aspects not frequently adopted by North American and European surgeons are emphasized. The review shows that nonadvanced achalasia is frequently treated by Heller's myotomy. Endoscopic treatment is reserved to limited cases. Treatment for end-stage achalasia is not unanimous. Esophagectomy was a popular treatment in advanced disease; however, the morbidity/mortality associated to the procedure made some authors seek different alternatives, such as Heller's myotomy and cardioplasties. Minimally invasive approach to esophageal resection may change this concept, although few centers perform the procedure routinely.

Letters to the Editor

Statements appearing here are those of the writers and do not represent the official position of THE AMERICAN SURGEON. Comments on any topic are invited; those accepted for publication will not be subject to major editorial revision but generally must be no more than 500 words in length. The editor reserves the right to publish replies and may solicit responses from authors and others.

Letters to the Editor

Statements appearing here are those of the writers and do not represent the official position of THE AMERICAN SURGEON. Comments on any topic are invited; those accepted for publication will not be subject to major editorial revision but generally must be no more than 500 words in length. The editor reserves the right to publish replies and may solicit responses from authors and others.

Notes on NOTES: The emperor is not wearing any clothes

Laparoscopic surgeons are a curious lot. When we were accused of surgical adventurism in the early 1990s and were ostracized from presenting our early findings at the American College of Surgeons, we decided to invest our academic achievements in the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). All of the early laparoscopic pioneers suffered the indignity of being the object of derogatory comments by the surgical establishment about ‘‘Nintendo’’ surgery (as if they knew what a video game was) and the ridiculousness of statements such as, ‘‘what’s wrong with a four-inch incision to remove the gallbladder that gets the patient back to work in 3 to 4 weeks?’’. We kept our council (silence), in spite of some misgivings, as the next technological revolution, robotics, swept the minimal invasive world. After the first year or so there were about 12–14 publications in our literature, all proclaiming this robotic surgery as being as ‘‘safe and effective’’ as laparoscopic surgery, but none actually proving it to be better. When the publications were looked at closely, all of the operations cost more and took longer (how is that effective?). While no one has actually said so, no one is taking robotics very seriously other than for its obvious use as a marketing tool. If there is anyone who thinks this million-dollar instrument has any utility in urology, I invite him or her to watch Dr. George Ferzli do a laparoscopic prostatectomy. Then, in 2006, we all heard about or saw a remarkable edited video of the removal of an appendix, albeit very normal appearing, through a gastroscope. By early 2007, there was one publication in a human subject about surgery done through a natural orifice transluminal endoscopic surgery (NOTES) technique, and that was about the rescue of a dislocated Percutaneous Endoscopic Gastrostomy (PEG), hardly something we see every day [1]. At the SAGES meeting in 2007 we were treated to edited videos that showed scopes introduced through the rectum, with stool affixed, used to guide surgery on gallbladders that were poorly grasped and dissected with no discernable anatomic landmarks, all often culminating in an explosion of bile. To those that state that these videos resemble the early era of laparoscopy, I paraphrase the Lloyd Bentsen/ Dan Quayle 1988 Vice Presidential debate: I knew the great surgical innovators of the early era of laparoscopy like Barry McKernan (gallbladder and hernia), Joe Petelin and Maurice Arregui (common bile duct), Dennis Fowler (colon), Lee Swanstrom (esophagus), Michel Gagner (adrenal and pancreas), and we never operated like that. If we did we certainly never filmed it. All of these pioneers did not work in traditional academic powerhouses but were rather busy general surgeons in smaller hospitals; such was the nature of early laparoscopy that in able hands it translated well from the open approach. At the SAGES 2007 meeting we were also treated to videos of endoscopic gastric plications (what exactly was plicated to what is difficult to determine), in the guise of performing an endoluminal vertical banded gastroplasty (VBG). In 2000 Michael Sarr’s group published excellent follow-up data on the VBG, showing that this operation worked to sustain weight loss less than 25% of the time and required reoperation about 20% of the time [2]. American surgeons have essentially abandoned this operation. It was Karl Marx who said that history repeats itself first as a tragedy and then as a farce. Why on Earth would we A. Pomp (&) Section of Laparoscopic and Bariatric Surgery, Frank Glenn Faculty Scholar in Surgery, Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA e-mail: alp2014@med.cornell.edu