General Surgery Applicants Research Articles

Factors influencing residency choice of general surgery applicants—how important is the availability of a skills curriculum?

Factors influencing residency choice of general surgery applicants—how important is the availability of a skills curriculum?

The Role of Laparoscopy in Trauma: A Ten-Year Review of Diagnosis and Therapeutics

Minimally invasive surgery has found many applications in general surgery. The role of laparoscopy in trauma has been debated as a diagnostic, as well as therapeutic, tool in hemodynamically stable patients. This study evaluated laparoscopy in the trauma population. A retrospective review of all laparoscopies performed in hemodynamically stable trauma patients from 1996 until 2006 was conducted. Mechanisms of injury, perioperative data, and demographic variables were analyzed using descriptive statistics and Student's t test. Exploratory diagnostic laparoscopy was performed on 102 patients. Laparoscopy was negative for 65 per cent of patients; 12 per cent of these were converted to laparotomy due to adhesions, hemoperitoneum, or surgeon preference. None of the conversions revealed intra-abdominal injury at laparotomy. An injury was diagnosed at laparoscopy in the remaining 35 per cent, with 55 per cent conversion rate to repair the injury. Therapeutic laparoscopy included serosal repair, hemorrhage control, diaphragmatic repair, and other standard laparoscopic treatments. No patient required re-exploration, there were no missed injuries or other complications, and no patient died in this study. Laparoscopy has an important diagnostic and therapeutic role in selected hemodynamically stable trauma patients. Using a minimally invasive approach can reduce the potential morbidity of negative laparotomy.

Creating a surgical education website: What is most important to the general surgery applicant?

Creating a surgical education website: What is most important to the general surgery applicant?

A Better Lifestyle During Surgical Clerkship May Not Increase Application Rates to General Surgery

Lifestyle has been identified by numerous studies as the number one deterrent to pursuing a career in general surgery. This study tests the hypothesis that a better lifestyle during general surgery clerkship correlates with a higher application rate to general surgery. Canadian Residency Matching Service data from the past 10 years were used to identify institution-specific application rates to general surgery. Through a survey of all fourth-year medical students applying to general surgery in Canada and Canadian undergraduate surgery program directors, the lifestyle of each general surgery clerkship was described and given a score. Multiple descriptions of the clerkship structure were obtained for every school in Canada to reduce recall bias, with an average of 4 sources per program. One school stood out as the most prolific producer of general surgery applicants, with an average of 7.9% of the total class applying to general surgery each year. This represented 80% more general surgery applicants relative to the national average (p < 0.05). Surprisingly, however, this institution also had the worst clerkship lifestyle score, having a higher call requirement, not sending their clerks home at noon post call, and placing a higher burden of responsibility on their clerks. This study suggests that a lifestyle-friendly surgical clerkship may not be necessary to increase recruitment into general surgery.

A New Technique in Closure of Burst Abdomen: TI, TIE and TIES Incisions

Burst abdomen is a continuing problem for the general surgeon as the incidence of such complication may reach 3% with a mortality rate exceeding 25%. New technique: A lateral incision is done from inside the abdomen along a line between the costal margin above to the iliac crest below in the area between the mid and anterior axillary line. According to the depth of the incision, the incision may either involve the transversus abdominus and internal oblique muscles (TI incision), or include in addition the external oblique muscle (TIE incision), or it may also involve the Scarpa's fascia (TIES incision). Such incisions would give an extra length on each side towards medial advancement. Eight patients, 5 men and 3 women aged 34-67 years, with burst abdomen after major gastrointestinal and hepatobiliary surgery failed to close primarily were managed using this technique. Long-term follow-up patients was done for development of complications. Electromyogram (EMG) for the rectus muscle and sensory loss for the abdominal wall were also tested. The distance between the 2 cut edges of the different release incisions was measured clinically (TIES incisions) or using ultrasound device (TI and TIE incisions). Scarpa's fascia biopsy was taken from 1 patient of the TIE group for histopathological study 6 years after surgery. One patient died on the third postoperative day (mortality 12.5%), and 2 patients developed sub-incisional abscesses (25%). No single case of re-burst occurred. Long-term follow-up showed no single case of incisional hernia in the site of the midline surgical incision, but incisional hernia did occur in all the sites of TIES incisions. Incisional hernia did not occur in the TI incision and, more strangely, neither did it occur in any of the TIE incisions. Follow-up of the incisions width showed a significant increase in width of the TIES with time while there was no significant increase in that of the TI or TIE. There was a sensory loss at and below the level of umbilicus in the TIES group. EMG showed evidence of motor affection to the rectus muscle at and below the level of the umbilicus in all groups. Scarpa's fascia biopsy was taken to try to find an explanation for the absence of incisional hernia in TIE incisions and was found to be 3 times as thick and the type I collagen was replaced by collagen type III. The new method described is simple, straightforward and tension free, with a comparable mortality and morbidity. The Scarpa's fascia adaptation and its ability to change have enormous applications in general and reconstructive surgery, but further evaluation of such phenomenon is needed.

Do General Surgery Applicants Really Want to be General Surgeons?

The authors sought to compare categorical general surgery applicants with applicants in other specialties regarding their final specialty-choice ranking for residency positions. The authors analyzed the 2004-match year applicant-pool data from the Electronic Residency Application Service and Common Application Service as well as rank-list data from the National Resident Matching Program (NRMP), the Urology Match Program, and the San Francisco Matching Program for 20 different specialties. Two-tailed chi-square tests measured differences between the proportions of applicants who ultimately ranked programs in categorical general surgery and each of 19 other specialties and between the proportions of U.S. students who ranked categorical general surgery and each of 19 other specialties as a non-preferred choice. A Bonferroni-adjusted alpha was set at 0.0013 to reduce the likelihood of a type I error. The proportion of applicants ranking each specialty ranged from 42% (786/1859) in pathology to 91% (282/31l) in neurological surgery. The proportion of categorical general surgery applicants ranking categorical general surgery programs was 51% (2004/3900), which was significantly lower than the proportions ranking 12 of 19 other specialties (each p < 0.001). Of the 2004 categorical general surgery applicants ranking categorical general surgery programs, 278 (278/2004, 14%) ranked categorical general surgery as a non-preferred specialty. Among 1230 U.S. students ranking categorical general surgery programs, 144 (12%) did so as a non-preferred specialty-a proportion significantly higher compared with U.S. students ranking 15 of 19 other specialties as non-preferred (each p < 0.001). In 2004, the categorical general surgery applicant pool was relatively uncommitted to the specialty of general surgery. The number of applicants ranking categorical general surgery as a non-preferred specialty was likely even higher than these data indicate, as unmatched applicants in non-NRMP matches who then ranked categorical general surgery programs in the NRMP were tabulated by the NRMP as having ranked categorical general surgery as their preferred specialty.

American Society for Bariatric Surgery’s guidelines for granting privileges in bariatric surgery

Bariatric surgeons, like those in other subspecialty areas of surgery, should be responsible for demonstrating a defined experience and exposure to the discipline’s unique cognitive, technical, and administrative challenges. The following guidelines define the degree of experience, exposure, and support considered to be minimally acceptable credentials for general surgery applicants to be eligible for hospital privileges to perform bariatric surgery. These guidelines are intended to be an update of the original guidelines enacted in 2003 [1].

The “Nordström Suture” to Enhance Serial Scalp Reductions and Other Serial Excisions as Well as to Treat and Prevent Scar Widening

The “Nordstrom Suture” started with our interest in tissue expansion, which resulted in quite several publications and an international textbook in this field. We became very familiar with biological and mechanical creep. Expanders and extenders were our main tools and we tried to find solutions to the problems we had with them. This led us to the development of the Nordstrom suture. The main indications for us for the suture so far have been (1) enhancement of serial reductions of bald scalp, burn scars, and so on; (2) prevention of scar widening in situations where proper plastic surgery techniques have not been able to prevent disfiguring scar widening. We believe this medical-grade superelastic suture will probably find many other applications in plastic, reconstructive, and general surgery.

Subsurface tissue lesions created using an Nd:YAG laser and a sapphire contact cooling probe

This study investigates deep laser coagulation of tissue in combination with contact cooling of the tissue surface for potential use in noninvasive procedures in urology. A laser probe was designed and tested for simultaneous Nd:YAG laser irradiation and sapphire contact cooling of liver and skin tissue samples, ex vivo. Gross and histologic examination was used to quantify thermal lesion dimensions. Liver lesions measured 5.5 +/- 0.3 mm in diameter, while preserving the tissue surface to a depth of 2.1 +/- 0.2 mm (n = 5). Skin lesions measured 4.3 +/- 0.9 mm in diameter, while preserving the skin surface to a depth of 1.1 +/- 0.2 mm (n = 6). There were no statistical differences in lesion diameter and layer of preserved tissue between contact (sapphire) cooling and prior non-contact (cryogen spray) cooling results for a given tissue type (P > 0.05). Noninvasive laser procedures targeting tissue structures for thermal coagulation within a few millimeters of the tissue surface are feasible and may expand the use of combined laser/cooling techniques for applications in urology and general surgery. In vivo animal studies are currently in development to optimize the laser and cooling parameters for potential clinical applications.

Expanded use of transplantation techniques: abdominal wall transplantation and intestinal autotransplantation

Surgical principles and techniques derived from organ transplantation surgery can provide novel applications in general surgery. We present an update on our 5-year experience with intestinal autotransplantation and abdominal wall transplantation. Nine patients underwent intestinal or multivisceral transplantation with the addition of 10 abdominal wall grafts to cover the large open areas from previous surgeries. Seven patients underwent near-total abdominal evisceration, ex vivo resection of masses at the base of the mesentery, followed by intestinal autotransplantation; 44% of the abdominal wall graft recipients are alive, but none of the fatalities were related to the graft itself. In two cases the graft had to be removed due to venous thrombosis. Of patients with intestinal autotransplants, 71% are alive with two mortalities due to recurrent metastatic malignancy. In only one case, the intestinal autograft had to be removed because of venous thrombosis. All surviving patients but one are on a regular diet; two are on supplemental enteral feeds. These results show that anastomotic and resection techniques derived from the experience in solid organ transplant can be utilized in complex wound closure, as is the case of abdominal wall transplantation, or resection of large retroperitoneal tumors with intestinal autotransplantation.

Endoscopic Application of Nd:YAG Laser in General Surgery: Technique and Results

Summary The aim of this retrospective study was to evaluate the value of Nd:YAG laser application in general surgery. From 1981 to 1996 1009 endoscopic therapies with Nd:YAG laser were performed in 580 patients. Lasers were applied to achieve recanalisation of benign and malignant stenosis in the gastrointestinal tract. 57 patients were treated for malignant esophageal stenosis. One perforation occurred. Quality of life could be improved in 50%. Mean survival was 7 months. Malignant stenosis of the rectum was treated in 279 patients. Two perforations of the rectum developed. Improvement of symptoms could be achieved in 52% of patients. Mean survival was 16 months. In conclusion Nd:YAG laser therapy proved to be an efficient instrument in palliative treatment of stenosing esophageal and rectal cancer and in selected benign diseases.

Laparoscopic approach to ovarian pathology in children and adolescents

Laparoscopic procedures are constantly finding wider application in general and pediatric surgery. The female child and adolescent presenting with suspected acute or chronic ovarian pathology may be an ideal candidate for laparoscopic surgery. From March 1992 to December 1993, six girls aged 7 to 18 years underwent seven laparoscopic operations for ovarian pathology at Childrens Hospital Los Angeles. Clinical presentations included virilization with primary amenorrhea (1), precocious puberty (1), malignant dysgerminoma (second look) (1), and abdominal pain (3). Postoperative diagnoses were dysgerminoma (1), bilateral gonadoblastoma in a 46 XY chromosomal phenotypic femal with dysgenetic gonads (1), negative bipsy (1), serous cystadenoma with acute torsion (1), ovarian cysts (1), and ovarian torsion (1). Operations performed were unilateral salpingo-oophorectomy (1), unilateral salpingo-oophorectomy with contralateral biopsy (2), bilateral salpingo-oophorectomy (1), diagnostic biopsy (2), and ovarian cystectomy with oophoropexy (1). There were no operative complications. One patient underwent two operations, a biopsy followed by unilateral salpingo-oophorectomy. Only one patient required a mini-laparotomy for delivering a large tumor mass. Mean operative time was 138 min, mean hospital stay 2.0 days. We encountered two malignant cases, which were definitively treated by laparoscopic resection. These two patients remained free of disease 12 to 18 months later. The laparoscopic approach to ovarian pathology in children and adoloscents in an effective method for diagnosis as well as definitive therapy. Our initial experience is presented followed by recommendations for clinical practice.

Initial experience with laparoscopic appendectomy.

As experience with laparoscopy increases, new applications in general surgery are being identified. Treatment of acute appendicitis through the laparoscope has been proposed. We present our initial experience with this new technique. Over a 12-month period, laparoscopic appendectomy was attempted in 29 patients. There were no intraoperative complications. Two cases required conversion to the open technique owing to gangrene at the appendiceal base. The average operating time was 64 minutes. Two of nine patients with perforated appendicitis developed a pelvic abscess, and one patient developed wound cellulitis. Pain medication requirements were minimal, bowel function returned rapidly, and half of the patients were discharged on postoperative day one or two and returned to normal activity within one week. Based on our initial experience, it appears that laparoscopic appendectomy is a safe and effective technique for managing acute appendicitis and offers advantages in terms of decreased pain, decreased hospital stay, and a rapid return to normal activities.

Experimental endoscopic subcutaneous surgery.

Endoscopic techniques have found increasing applications in general surgery. In this article, an attempt has been made to utilize endoscopy via a subcutaneous approach in an experimental pig model for dissection of fat, muscle, and fascia.

Simple and inexpensive delivery of halogenated inhalation anesthetics to rodents.

Halogenated inhalation anesthetics offer several advantages over injectable anesthetics for small-animal surgery. Benefits include rapid induction, easy adjustment of anesthetic depth, and a short period of recovery. Although the cost of most inhalation anesthetics is low, present delivery systems are often prohibitively expensive for rodent uses. This report describes a low-cost, portable system that can be used with halothane or isoflurane for general surgery or stereotaxic applications with or without intubation. Also included is a description of rodent nose cones for both general surgery and stereotaxic surgery that allow for simple evacuation of waste gases.

Current laser applications in general surgery.

Current laser applications in general surgery.

Senior registrar applications in general surgery in 1982 and 1985

Senior registrar applications in general surgery in 1982 and 1985

Lasers in general surgery.

AbstractLaser technology has wide application in general surgery. The CO2 laser functions as a scalpel sealing small blood vessels in the process of dividing tissues. The YAG laser has been especially useful in the performance of liver resection and the coagulation of large vascular tumors. The utility of lasers in various types of general surgical procedures is discussed.

Laparoscopy in general surgery

In the last seven years laparoscopy has become increasingly popular in North America. The procedure has been mainly embraced by the gynecologist. Other specialities have been relatively slow in recognizing its value. Laparoscopy has wide applications in general surgery. It is a useful tool in blunt abdominal trauma and often prevents laparotomy. In patients with acute abdominal conditions, when findings are atypical, uncertainty in diagnosis may be resolved by laparoscopy. In patients with malignant disease it permits assessment of the extent of the lesion and enables accurate selection of the mode of therapy. Numerous procedures per laparoscopy, including biopsies, division of adhesions, cholangiography and collection of samples for bacteriologic studies, may be carried out simultaneously. Complications associated with the procedure are few but may be severe. These can be avoided by careful adherence to proper technic.

Cocaine Analgesia; Its Extended Application in General Surgery, When Hypodermically Employed

Cocaine Analgesia; Its Extended Application in General Surgery, When Hypodermically Employed