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| July 2008 |
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An official publication of the American College of Surgeons |
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EDITORIAL CHAIR | |
| Wiley W. Souba, MD, ScD, FACS | ||
| EDITORIAL BOARD | ||
| Mitchell P. Fink, MD, FACS | William H. Pearce, MD, FACS | |
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Gregory J. Jurkovich, MD, FACS | John H. Pemberton, MD, FACS |
| Larry R. Kaiser, MD, FACS | Nathaniel J. Soper, MD, FACS | |
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name to send email to the editor. |
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| IN THIS ISSUE |
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The Fundamentals of Laparoscopic Surgery (FLS) Program |
| Parotidectomy |
| Thyroid and Parathyroid Operations |
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Minimally Invasive Esophageal Procedures |
| CME
Program |
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| THE BEST SURGICAL THINKING |
The Fundamentals of Laparoscopic Surgery (FLS) Program: Its Time Has Come!
DOI 10.2310/7800.2008.NCjul
The incorporation of laparoscopic surgery into the armamentarium of general surgeons occurred rapidly in the early 1990s. There was a distinct " learning curve" during the uptake of laparoscopic cholecystectomy, with an increase in bile duct injuries.1 Much of the education offered on laparoscopic techniques for established surgeons was provided by industry, and many surgeons learned " one-handed" operating techniques, whereas the underpinning cognitive aspects unique to laparoscopy were given short shrift. In the late 1990s, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) began developing the Fundamentals of Laparoscopic Surgery (FLS), a program designed to cover the cognitive and psychomotor aspects unique to laparoscopic surgery, associated with a mechanism for assessment. It was not SAGES' intent to develop a certifying examination but rather to provide tools for the teaching and assessment of the cognitive knowledge, technical skills, and clinical judgment related specifically to basic laparoscopic surgery. The final product was the result of the combined effort by many surgical experts, educators, and administrators and represents one of the first fully developed competency evaluation tools available for surgeons.2,3
The FLS program consists of two components: a teaching module for education and an examination to assess competency. The cognitive portion includes didactics in four broad content areas: preoperative considerations, intraoperative considerations, basic laparoscopic procedures, and postoperative considerations. The content was heavily vetted among experts in laparoscopy for being essential for basic laparoscopic surgery. The second portion of the training outlines the manual skills training practicum based on a training program developed by Fried and colleagues at McGill University.4,5 This module includes five " watch and do" exercises, which are measurable and designed to allow students to practice and improve their laparoscopic skills.
" Competence" is assessed through a two-part examination. The cognitive examination consists of a timed, secure test with multiple-choice questions and clinical scenarios. These questions and scenarios were subjected to rigorous oversight by medical educators2,3 and were designed to withstand " high-stakes" scrutiny. The manual skills test assesses five basic techniques (peg transfer, pattern cutting, ligating loop, intracorporeal knot, extracorporeal knot) based on efficiency and precision. This examination is proctored, taken on standardized training boxes with uniform equipment, and occurs at designated testing locations. This manual skills test has been subjected to extensive validation by the McGill group; the scores correlate with laparoscopic experience and are transferable to the operating room environment.4,5
After developing the teaching and evaluation modules of the FLS program, it was subjected to beta testing at seven designated centers. Surgical trainees from different levels and practicing surgeons took part in this evaluation, which has been reported elsewhere.3 The beta test results for the FLS examination demonstrated satisfactory reliability, appropriate psychometric properties, and substantial validity.
In 2005, the American College of Surgeons (ACS) partnered with SAGES to lend support to this first fully developed competency evaluation tool available for surgeons. Since that time, great momentum has developed around the FLS program. Many general surgery residency programs have incorporated FLS as a key component of laparoscopic training. The joint ACS-APDS (Association of Program Directors in Surgery) technical skills curriculum includes the components of the FLS program in its laparoscopic modules. Several hospitals have mandated that surgeons practicing laparoscopic surgery must have passed the FLS examination to be privileged to perform laparoscopy. At least one captive malpractice insurance company has incentivized participating surgeons to attain FLS certification. There has also been increased interest in the FLS program from international surgeons. For instance, the Royal Australasian College of Surgeons has now incorporated FLS into its training programs and board certification process.
Despite these initiatives, there was concern that the price of the FLS program is prohibitive for most general surgery residencies. In response to this concern, the Covidien Corporation recently funded a large educational grant to SAGES to allow rapid dissemination among surgical training programs. This generous grant will allow each general surgery resident training program in the United States and Canada to obtain one of the FLS video training boxes as part of their Residency Review Committee-mandated simulation effort.Furthermore, vouchers for completing the testing component of FLS will be supplied for each graduating chief resident in general surgery and to fellows in gastrointestinal surgery fellowships. Notices have gone out to all program directors informing them of the ability to obtain these resources. It thus seems likely that FLS will be incorporated in virtually all North American training programs.
In summary, the FLS program was developed because of an identified need to educate surgeons in the underlying principles and basic skills of laparoscopic surgery and because of the growing demand to document competency in surgical practice. The program has been extensively vetted by experts and validated in beta testing. The inclusion of a testing component ensures that competency in laparoscopy is both taught and evaluated. Given the partnership with the ACS, the growing recognition of FLS internationally, and the recent Covidien grant allowing widespread adoption by general surgery trainees, the FLS program should achieve wide dissemination and improve the safety of patients undergoing laparoscopic surgery.
References
1. Strasberg SM, Hertl M, Soper NJ: An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995180:101, .
2. Peters JH, Fried GM, Swanstrom LL: Development and validation of a comprehensive program of education and assessment of the basic fundamentals of laparoscopic surgery. Surgery 2004135:21, .
3. Swanstrom LL, Fried GM, Hoffman KI, Soper NJ: Beta test results of a new system assessing competence in laparoscopic surgery. J Am Coll Surg 2006202:62, .
4. Derossis AM, Fried GM, Abrahamowicz M: Development of a model for training and evaluation of laparoscopic skills. Am J Surg 199815:482, .
5. Fried GM, Feldman LS, Vassiliou MC: Proving the value of simulation in laparoscopic surgery. Ann Surg 2004240:518, .
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| THIS MONTH'S UPDATES |
2 Head and Neck
6 Parotidectomy
DOI 10.2310/7800.S02C06
Most parotid tumors are benign, necessitating only superficial parotidectomy.
The parotid gland, the largest of the salivary glands, occupies the space immediately anterior to the ear, overlying the angle of the mandible. The portion of the parotid gland lateral to the facial nerve (about 80% of the gland) is designated as the superficial lobe; the portion medial to the facial nerve (the remaining 20%) is designated as the deep lobe. Deep lobe tumors often present clinically as retromandibular or parapharyngeal masses, with displacement of the tonsil or the soft palate appreciated in the throat. The overwhelming majority of parotid tumors, however, are benign and lateral to the facial nerve. This chapter focuses primarily on superficial parotidectomy.
Operative Technique for Parotidectomy
The incision begins immediately anterior to the ear, continues downward past the tragus, curves back under the ear (staying close to the earlobe), and finally turns downward to descend along the sternocleidomastoid muscle. Skin flaps are then created to expose the parotid gland. The posterior-inferior skin flap is then elevated in a similar manner.
Once the skin flaps have been developed and retracted, the next step is to identify the facial nerve. Usually, the nerve may be identified either at its main trunk (the antegrade approach) or at one of the distal branches, with subsequent dissection back toward the main trunk (the retrograde approach). For a lateral parotidectomy, our preference is to identify the main trunk first (unless it is thoroughly obscured by tumor or scar), keeping in mind that the nerve typically lies deeper than one might expect.
Once identified, the plane of the facial nerve remains uniform throughout the gland (unless the nerve is displaced by a tumor) and serves to guide the parenchymal dissection, which proceeds directly over the facial nerve. We do not regularly resect the entire lateral lobe of the parotid gland unless the tumor is large and such resection is required on oncologic grounds.
Complete superficial parotidectomy with full dissection of all facial nerve branches is seldom necessary, although, in some cases, it is mandated by tumor size or histologic findings. The question of whether to sacrifice the facial nerve almost invariably arises in the setting of malignancy. In our view, this measure is seldom necessary. Benign tumors tend to displace the nerve, not invade it. Sacrifice of the nerve probably does not enhance survival.
Before closure, absolute hemostasis is confirmed. Facial nerve function is evaluated in the recovery room, with particular attention paid to whether the patient is able to close the eyelid.
Complications of Parotidectomy
Studies have found that transient paralysis of all or part of the facial nerve occurs in 17 to 100% of patients undergoing parotidectomy, depending on the extent of the resection and the location of the tumor. Fortunately, permanent paralysis is uncommon, occurring in fewer than 5% of cases. The primary complications are gustatory sweating, sialocele, and cosmetic changes.
Gustatory sweating, or Frey syndrome, occurs in most patients after parotidectomy; it has been seen after submandibular gland resection as well. The symptom complex includes sweating, skin warmth, and flushing after chewing food and is caused by cross-innervation of the parasympathetic and sympathetic fibers supplying the parotid gland and the overlying skin. Sialocele, or salivary fistula, has been reported to occur after 1 to 15% of parotidectomies. Parotidectomy creates a hollow anterior and inferior to the ear, which may extend behind the mandible and may reach a significant size in patients with large or recurrent tumors. Strictly speaking, this cosmetic change is a necessary feature of the procedure, not a complication.
Outcome Evaluation of Parotidectomy
With proper surgical technique, superficial or partial superficial parotidectomy can be performed safely and within a reasonable operating time.
2 Head and Neck
9 Thyroid and Parathyroid Operations
DOI 10.2310/7800.S02C09
The operative techniques for thyroidectomy and parathyroidectomy are similar, and avoiding injury of the laryngeal nerves is paramount.
Operative Technique for Thyroidectomy
Before thyroidectomy, laryngoscopy is essential to determine whether the vocal cords are functioning normally. Thereafter, as a rule, dissection should always begin on the side of the suspected tumor; if there is a problem with the dissection on this side, a less than total thyroidectomy can be performed on the contralateral side to prevent complications. The thyroid gland is exposed via a midline incision through the superficial layer of deep cervical fascia between the strap muscles. However, if they are adherent to the underlying thyroid tumor, the portion of the muscle adhering to the tumor should be sacrificed and removed en bloc with the specimen.
When a thyroid lobectomy is performed, the isthmus of the thyroid gland is usually divided lateral to the midline, taking care not to cut across the tumor. Once the isthmus has been divided, dissection is continued superiorly, laterally, and posteriorly. It is essential to avoid injuring the external branch of the superior laryngeal nerve (responsible for tensing the vocal cords).
The lower parathyroid gland is usually encountered during lateral mobilization of the lower thyroid pole. The carotid sheath is retracted laterally, and the thyroid gland is retracted anteriorly and medially. This retraction puts tension on the inferior thyroid artery and consequently on the recurrent laryngeal nerve, thereby facilitating identification of the nerve. The right and left recurrent laryngeal nerves must be preserved during every thyroid operation. In identifying the recurrent laryngeal nerves, it is helpful to remember that they are supplied by a small vascular plexus and that a tiny vasa nervorum runs parallel to and directly on each nerve.
The pyramidal lobe (found in about 80% of patients) is mobilized by retracting it caudally and by dissecting immediately adjacent to it in a cephalad direction. Once the parathyroid glands have been carefully swept or dissected from the thyroid gland and the recurrent nerve has been identified, the thyroid lobe can be quickly resected.
Special Concerns of Thyroidectomy
On rare occasions, thyroid or parathyroid cancers may invade the trachea or the esophagus. As much as 5 cm of the trachea can be resected safely without impairment of the patient's voice. If the invasion is not extensive and is confined to the anterior portion of the trachea, a small section of the trachea that contains the tumor should be excised, and a tracheostomy may be placed at the site of resection. Lymph nodes in the central neck (medial to the carotid sheath) are frequently involved in patients with papillary, medullary, and Hürthle cell cancer. These nodes should be removed without injury to the parathyroid glands or the recurrent laryngeal nerves. A median sternotomy is rarely necessary for removal of the thyroid gland, but if one proves necessary, the sternum should be divided to the level of the third intercostal space and then laterally on one side at the space between the third and fourth ribs.
Complications of Thyroidectomy
The most significant complications of thyroidectomy are injury to the recurrent laryngeal nerve, hypoparathyroidism, bleeding, injury to the external branch of the superior laryngeal nerve, infection, seroma, or keloid.
Parathyroidectomy
The preparation for parathyroidectomy is similar to that for thyroidectomy. The gold standard operation for primary hyperparathyroidism remains bilateral neck exploration; however, the excellent results of preoperative imaging with sestamibi scanning and ultrasonography, coupled with the availability of rapid intraoperative parathyroid hormone assays, have made unilateral focused exploration feasible for well-localized parathyroid adenomas. The complications of parathyroidectomy are similar to those of thyroidectomy but occur less often.
4 Thorax
8 Minimally Invasive Esophageal Procedures
DOI 10.2310/7800.S04C08
Treating benign esophageal disorders with minimally invasive laparoscopic procedures yields results comparable to those of treatment with traditional operations.
The development of laparoscopic surgery over the past 20 years has caused a significant shift in the treatment of benign esophageal diseases. Consequently, minimally invasive surgery is increasingly considered first-line treatment for achalasia, and laparoscopic fundoplication is considered more readily and at an earlier stage to manage gastroesophageal reflux disease (GERD). Here we focus on the operative procedures for the most common minimally invasive approaches.
Laparoscopic Nissen Fundoplication
All candidates for laparoscopic fundoplication should undergo (1) symptomatic evaluation, with symptoms graded with respect to their intensity both before and after the operation; (2) an upper gastrointestinal series, to diagnose an existing hiatal hernia; (3) endoscopy, to confirm a symptom-based diagnosis of GERD; (4) esophageal manometry, which provides useful information about the motor function of the esophagus; and (5) ambulatory pH monitoring, the most reliable test for the diagnosis of GERD. Once the operation is complete, the greatest complication is esophageal or gastric perforation.Optimal management consists of laparotomy and direct repair.
Laparoscopic Partial (Guarner) Fundoplication
Preoperative evaluation and operative planning are essentially the same for partial (Guarner) fundoplication as for Nissen fundoplication, and many of the surgical steps are the same. Over the years, however, it has become evident that a partial fundoplication is not as durable as a total fundoplication. As a result, total fundoplication is currently considered the procedure of choice for patients with GERD, regardless of the strength of their esophageal peristalsis.
Laparoscopic Heller Myotomy with Partial Fundoplication
Today, laparoscopic Heller myotomy with partial fundoplication has supplanted left thoracoscopic myotomy as the procedure of choice for esophageal achalasia. Candidates should undergo a thorough and careful evaluation to establish the diagnosis and characterize the disease. Many of the steps in a laparoscopic Heller myotomy are the same as the corresponding steps in a laparoscopic fundoplication; intraoperative endoscopy is where the operative technique differs, and great care must be taken not to perforate the esophagus. The results obtained to date with laparoscopic Heller myotomy and partial fundoplication are excellent and are generally comparable to those obtained with the corresponding open surgical procedure.
Left Thoracoscopic Myotomy
Currently, we consider a left thoracoscopic myotomy for patients in whom multiple previous abdominal procedures (done to treat other diseases) would preclude a laparoscopic approach. Preoperative evaluation is essentially the same as that for laparoscopic Heller myotomy. The results obtained with thoracoscopic myotomy are generally comparable to those obtained with corresponding open surgical procedures. Delayed esophageal leakage is a common postoperative complication.
Reoperation for GERD
Currently, an increasing number of patients are being seen for evaluation and treatment of foregut symptoms after laparoscopic antireflux surgery. If the symptoms persist or heartburn and regurgitation occur, a thorough evaluation (with barium swallow, endoscopy, esophageal manometry, and pH monitoring) is carried out.
We do not routinely attempt a second antireflux operation laparoscopically, and the optimal procedure depends on the original approach (open versus laparoscopic), the severity of the adhesions, and the specific technique used for the first operation (total or partial fundoplication). Because the risk of gastric or esophageal perforation or damage to the vagus nerves is much higher during a second antireflux operation, the surgeon must proceed with extreme care, making sure to identify structures completely before dividing them. The success rate falls to 70 to 80% for a second such operation.
Reoperation for Esophageal Achalasia
Laparoscopic Heller myotomy improves swallowing in more than 90% of patients. What causes the relatively few failures reported is still incompletely understood. Typically, a failed Heller myotomy is signaled either by persistent dysphagia or by recurrent dysphagia that develops after a variable symptom-free interval following the original operation. There are two treatment options for persistent or recurrent dysphagia after Heller myotomy: pneumatic dilatation and a second operation tailored to the results of preoperative evaluation.