Monday, December 31, 2007

No chance

Horrible case Saturday night. A 65 year old dialysis patient with CAD/DM/HTN came in through the ER hypotensive following a dialysis treatment. He intitally complained of some abdominal pain with nausea. As the day progressed, the abdominal pain increased, becoming intolerable by the evening. I was consulted at that time and when I looked at the above CT, I knew it was game over. But the guy was totally coherent. We chatted about the Browns. He was making puns. Just a happy, regular guy. I said, listen, it doesn't look so good for you. He wanted me to do everything though; he had a new girlfriend and he wasn't ready to die yet. So I agreed. I took him for OR and I found gangrene of the the entire stomach, duodenum and 75% of the small bowel. The colon was compromised but not necrotic. I did a quick Mattox maneuver, just to see how bad the abdominal aortic branches were, and I couldn't feel anything in the SMA or celiac artery at their origins. The aorta itself was hard and stiff, like a bamboo shaft. He must have either tossed an embolus to both or had concommitant acute thrombosis. Basically an unsalvageable situation. I've never seen pneumatosis that involved mainly the stomach and duodenum like this. There are fewer organs in the body as well vascularized as the stomach. Ischemic gangrene of the gastroduodenal complex requires an extensive vascular compromise.

So I anticipate the inevitable "why the hell did you operate" question. Why would I operate on someone with CT scan that showed basically dead stomach and duodenum? It's not like I was going to be able to resect the third and fourth parts of the duodenum safely. Well, maybe I shouldn't have. He had no chance. But I propose two reasons:
1. The guy wasn't gorked out on a vent when I saw him. He was awake and coherent, even charming. He wanted everything done. We were giving him morphine every five minutes, significant doses. He was going to die no matter what and it was either going to be in that ICU room, conscious and in pain, or after a quick trip to the OR, sedated and intubated and unaware of the catastrophe ravaging his system. The latter seemed more humane to me.
2. Practice. Sounds ghastly, I know. But you don't get to do a Mattox maneuver very often. It was clear 30 seconds after opening the peritoneal cavity that I was just going to close. The Mattox added six or seven minutes to the case. Maybe some day a young trauma victim will roll into the ER with a belly full of blood and I'll have to do a similar vascular exposure to repair some injury to the SMA or Celiac. You could say I performed unnecessary, gruesome surgery on this guy; I prefer to think I was able to use the terminal event in the guy's life as a gift, in order to hone a skill that could someday save someone else's life.

Saturday, December 22, 2007

SurgeXperiences 111

Hey, let the good times roll! Welcome to the ultimate blog carnival for all things surgical! Exclamation points! Things have been a little hectic, being the end of the year and all, but I hope you enjoy a sampling of submissions from surgical stories around the world. I suppose the theme ought to have something to do with Christmas, but most of the submissions I received were a little on the somber side. So just pretend that there's a holiday cheer vibe coursing through the proceedings. Since case studies were a lacking this month, I decided to post one. Guess the diagnosis and treatment by the end of this carnival and I owe you some sort of super duper prize: 52 year old guy with a history of hepatitis C and B who presents with LUQ pain. He appears non-toxic, is afebrile and hemodynamically stable. He's uncomfortable with palaption of the left upper quadrant but without peritoneal signs. Abnormal labs include WBC of 1400 and hemoglobin 8.0 and platelets 48,000. Liver function tests are normal. CT abdomen/pelvis shows edema and fat stranding around distal pancreas and splenomegaly. That's all you get. And no cheating.

On to the Carnival:

Bongi gets the holiday season off to a rousing start with a post about the thrills of spending Christmas taking care of drunken revelers in the trauma bay. He also posts a potentially controversial story about "practicing" on a hopeless patient. Very compelling stuff.

The Monash medical student submits a nice review on the science of music in the OR. I love it that people are doing research and writing papers about something like this. In my OR I find I get agitated easier if there's no music. I like Coltrane or something mellow like Moby/Grateful Dead/Phish (but not classical, puts the rest of the OR team into a soporific trance) for long or difficult cases. For shorter, end of the day cases I like something with a little more tempo. The IPod shuffle is surprisingly not as satisfying; too much variety in genres. You're all over the place; Barber's Adagio for Strings followed by Metallica. Too jarring. I pick a CD and stick with it to the end. Anyway, those are my thoughts on OR tunes.

Great review of the history of artifical implants in medicine by Lakshmi from the blog Nanoscience.

Suture for a Living continues her consistently strong work with a highly informative post detailing the difference in anatomy, technique, and coding between panniculectomy and abdominoplasty. There's also great historical and technical review of reduction mammoplasty from a couple days ago. So many medical blogs are off the cuff and spontaneous, it's nice to read one that is so well researched and honed. Check it out.

Amusing little feature from Plasticizer about a "special" wine glass on sale for Christmas. If you have a long, unsightly nose, please forget it was me who linked this.

White Coat Rants reminds us all that the things we wear beneath our clothes aren't always private; you never know when you'll end up in a trauma bay.

Dr. Bruce Campbell, an ENT specialist from Wisconsin, writes about the way a veteran surgeon visualizes a major operation; not from beginning to end, but in retrospect. Very insightful. Plus, he quotes Kierkegaard at the beginning, thereby ensuring that you add a couple points to the old IQ by the end. He also has a great post about the "collaborative" nature of decision making in the modern physician/patient relationship, especially with regard to cancer treatment options. Younger patients, especially women with breast cancer, studies show, are more likely to be active participants in decisions. I have found this to be true myself. Conversely, older patients tend to be more passive; a whatever you think is best, doctor, sort of attitude. This is spot on as well. Old guys with colon cancer invariably shrug and say "you're the doctor. You tell me what to do" after you go through all the options and risks.

Dr Val writes about an unsatisfying experience with an orthopedic consultant for a mysterious elbow ailment. Every other week or so I'll get a lady with chronic abdominal pain in the office who has bounced around from PCP to GI doc to OB/Gyn without a diagnosis. It can be very frustrating for patient and doctor.... just goes to show, the human body isn't a car that you can simply run through a diagnostic computer. Some things, we'll never figure out.

From the blog Ten out of Ten comes a post about an ER doc trusting his instincts and relentlessly chasing down the true diagnosis; excellent job!

Dr Alice
blogs about her first awkward experience telling a patient that he has cancer. We've all been there. It doesn't come naturally, breaking awful news to someone.

Bright Lights, Cold Steel relates an unfortunate bad outcome after a gastrectomy/vagotomy. Leaks happen; the lesson, as always, is that survival correlates with identifying them early.

Counting Sheep recounts a story about enduring a five hour hopeless vascular surgery case, raising the important question: if what we're saving isn't compatible with dignified life, then is it worth the cost and effort to go through the exceedingly complex motions of saving it? Incidentally I like the phrase "mis-surgeonist". Pretty clever.

Panda Bear and myself also address the issue of futile care in posts from last week. Draw your own conclusions, or at least think about the ramifications of our ability to salvage patients from what had historically been death sentences with advances in critical care and increased understanding of the pathophysiology of SIRS/multiple organ failure.

On a lighter note, a cool little anecdote from Donorcycle about the distractible surgeon and how sometimes everyone is better off if you just stick a scalpel in his hand. My thoughts exactly!

No surgical carnival would be complete without at least something from Sid Schwab at Surgeonsblog. Although he hasn't posted anything new lately, here's a link to the "Sampler" post that gives an organized platter of great writing, insight, and humor.

Some other random tidbits: Orac on the Blue Man. Cameras built into light handles, allowing better filming of operations. A goofy simulation of what to do when a fire breaks out in the OR; my wife (an anesthesiologist) found it somewhat ridiculous. Someone also sent me a submission that basically was an add for mesothelioma screening; no thanks. That was part of the reason why I got rid of my AdSense; after I posted the inguinal hernia review, the little box at the bottom kept advertising for a law firm that specialized in Kugel Patch recalls and how to go about suing your horrible surgeon for malpractice. Yeah, I think I can do without the extra 26 cents a month that AdSense brings in. Anyway, Season's Greetings and Happy New Year to everyone. And thanks for all the submissions. Hosting the carnival is a great way to get introduced to all the medical blogs out there you wouldn't normally get to peruse. I strongly encourage those who haven't hosted to do so. No word on who's doing edition 112; volunteer if you can.

And the answer is: Splenic Vein Thrombosis, likely secondary to pancreatitis. No gastric or esophageal varices on endoscopy, but the pancytopenia of splenic sequestration would be the indication for splenectomy. The GI guy, however, is concerned about distal pancreatic neoplasm (doesn';t look like it to me) and wants to get endoscopic ultrasound/biopsy done first. Doesn't seem to me that EUS would change the plan, but whatever.

Thursday, December 20, 2007

Hot Rod

This is priceless. Apparently some "surgical staff member" felt compelled to make an anonymous phone call to the newspapers, thereby creating a media frenzy. Now the stupid chief resident who took the picture with his cell phone faces suspension or even termination, and possible future legal recrimination. Obviously a dumb, spur of the moment thing to do, but I think anyone who participates in operations for a living can relate a similar scenario where an unconscious patient is exposed and something humorous is revealed; the fat guy with pubic hair shaved in a thin strip, x-rated tatoos on an elderly lady's buttock, etc. Everyone chuckles, but you move on. Not a word is spoken after the case to the patient or anyone else. Taking a picture...... a line gets crossed when you try to capture a vulnerable moment in the OR and share it with others outside the actual case. Just a dumb, dumb thing to do.


I was in the ER yesterday seeing a consult when I noticed a goddawful odor in the slot next to me. Nurses were actively spraying the hall with deodorizer as I asked what the hell was going on. Oh, it's actually a guy you know, I was told. The nursing home sent him over. I read the chart and realize it's an old guy I had operated on about 6 months prior for fulminant c diff colitis. I did a total colectomy and end ileostomy. He was a demented old guy, but in relatively good overall health. Somehow he survived the c diff episode and recovered and was transferred to a long term care facility. Apparently he had developed sudden hypotension and tachycardia and the nursing home sent him right over. No mention was made of the sickening odor the poor guy was emitting on any of the transfer forms. I say hello to his wife, who was sitting ever vigilantly by his bedside, and examined him. The belly looked fine. Stoma functioning well. The nurse helped me roll him over and the sight was something out of Night of the Living Dead. I've seen some nasty decubitus ulcers in my time, but this was absolutely horrifying. The skin and subcutaneous tissue had almost liquefied and a black dead escar extended almost to his lumbar spine like a glaze. His WBC 24k. Lactate 2.8. Pressors already started. We carted him to ICU and I got three nurses to help roll him over again. In these situations you don't need anything fancy. A clamp to grasp tissues and something sharp to cut it with. I found a hemostat and a scalpel in the supply room and went to work. And by "work" I mean literally filleting chunks of dead flesh from his sacral area. Two nurses had to leave secondary to near fainting or extreme nausea. I could feel the odor seeping into my pores. You cut and cut until you get tissue that bleeds. Must have been a pound or two of gunk on the bed by the time I was done. He didn't feel a thing. I hadn't done something like this since early residency; senior level surgical staff always tries to pawn off the crapola decubitus cases on juniors. But the guy needed it. He was septic and dying from an ulcer. He's doing much better today.

Decubitus ulcers are a problem in institutionalized patients. Studies suggest that all it takes is 32 mmHg of pressure applied to an area for two consecutive hours to overcome capillary pressure and thereby impede perfusion of cells. The typical mattress applies 150mmHg of pressure. Pressure sores are an epidemic in certain patient populations: para/quadraplegics, the demented, institutionalized patients, and patients on vents in the ICU. Precautions such as off loading and frequent rolling of the patient and some of the newer air mattresses can help, but the work that goes into prevention can be taxing to nursing personnel. Especially in nursing homes. It's troubling though, nonetheless, that an institution in the United States of America would allow an ulcer to progress to this level of rancidness. I'm certain that odor didn't acutely present itself.

Wednesday, December 19, 2007

San Antonio Breast Cancer Symposium

Medpage is a good site to check out. This month it gives a good review of several of the articles presented at the San Antonio Breast Cancer Symnposium. Over twenty articles are available for review and free CME credit is given after you read each one (just answer two or three questions based on what you read). A couple of highlights:
1. As breast conservation therapy has increased, the use of breast irradiation has not risen accordingly; troubling in that lack of radiation after lumpectomy doubles your risk of recurrence.

2. An interesting study detailing the arbitrary five year cutoff for Tamoxifen; ten years may be beneficial. Of course, with the enthusiasm now for aromatase inhibitors, the argument may become obsolete.

3. Speaking of aromatase inhibitors, there's an article that describes an extended benefit past completion of treatment with Arimidex.

4. A good meta-analysis on the negligible benefits of high dose chemotherapy for advanced breast cancer.

5. Another study that questions the use of antracyclines (long a primary agent) as adjuvant therapy for all women with breast cancer.

Monday, December 17, 2007

Futile Care

The idea of futile care is shockingly new in the American health consciousness. The fact that it has become controversial is a testament to the amazing advances we've made in critical care and the preservation of life in the face of multiple organ failure and overwhelming sepsis. Patients are now surviving hemodynamic insults that, 30 years ago, would have been obligatory death sentences. It's truly a remarkable feat in scientific and technological innovation. Critically ill patients are leaving hospitals mere weeks after being almost completely supported by machines. Dialysis and mechanical ventilators replace native organs temporarily, allowing for kidneys and lungs to recover. New antibiotics are able to strike at highly resistant "superbugs". ICU's provide a setting of heightened vigilance so that every change is noted. Highly specialized intensivist teams are there to catch the slightest perturbation in patient performance. It's labor intensive, stressful, and extremely expensive; but it often works. We're literally bringing people back from the dead. The question is: how do you know when the situation has become "futile" and what do you do when you reach that threshold?

In the Panda Bear Blog, this issue is addressed at great length in the unfortunately titled post, "Putting Granny Down". Much of the piece is well written and insightful but the essential point is that we spend far too much money on patients who don't derive any benefit from such intervention. He speaks of the 90 year old nursing home patient, demented and incontinent who gets admitted with urosepsis every two months or so, lacks a DNR order and ends up in the ICU with 15 consultants on board managing his/her multiple organ failure, but in the end, merely delaying the inevitable. Point taken. Not a good situation. Not a good use of limited resources. But put Granny down? Did granny ask to be in this situation? Is it her fault that she's "such a burden" to society? Isn't there a more dignified way to handle the last days of a human being? The reality of the situation is that most ICU's aren't filled with 90 year old demented bags of bones. Believe it or not, there's actually humans in those rooms. Humans across the age spectrum with families and and lives and pasts and even hopes for the future. That hope depends on the efforts of the doctors and nurses providing meticulous, round the clock care. And it ain't cheap. Good outcome or no.

I won't pretend to have all the answers. ICU's will always be expensive. The latest chemotherapy drug will always be expensive. The newest titanium product in hip replacement surgery will always be expensive. The idea that innovation in medicine will be rewarded financially drives much of the research and development that goes on in BigPharm, biotech, and engineering firms. This is a good thing. The high cost of American health care is more a function of the high quality of cutting edge American health care, rather than of wasteful spending on barely conscious Gomers. The problem isn't granny getting too old. The problem is we don't have a system in place to handle this emerging paradigm of how people die. The days of grandpa passing away peacefully at the family homestead of "natural causes" is becoming more and more rare. The elderly are dying with increasing frequency in hospitals and nursing facilities. Death has become a public burden, witnessed by nurses and aides and doctors, and, as a result, has become much more expensive. So what can we do?

1.Make a law requiring every American to have power of attorney/living will/advanced directive documents complete by a certain age. You can't drive without car insurance; why is it ok to enter the twilight of life unprepared for the inevitable decline? At age 60 or so, you sit down and decide what you want to happen when you become ill or are unable to make conscious decisions on your own. Seems simple enough, right?

2. Patients who are deemed unsalvageable, but not close to death (think of the 75 year old guy with good cardiac function who has suffered a major stroke, is dependent on the ventilator, has bed sores, and requires dialysis three times a week but has no idea who or where he is anymore) need to be evaluated by some sort of hospital ethics board. If deemed that ongoing care in the ICU is "futile" then further continuation of such care will need to be paid out of pocket by family members. Major questions arise, obviously, over who this "ethics board" is and why and how they arrive at their decisions. It can be standardized though. If x number of criteria are met, the patient qualifies as a "futile case" and appropriate designation is relayed to the insurance company. The sense of guilt and responsibility is removed from the shoulders of hospitals and health care providers and transferred to involved family members. And maybe that's where it belongs. It may seem cold-hearted, but it's certainly better than "putting down granny".

I think the topic carries with it major philosophical implications. What is life. When is a being not the being he/she was prior to such catastrophic event. The very process of dying has been altered; rather than a quick deterioration and "dying in your sleep", we now face the distasteful possibility of long, slow, drawn out loss of function, viability, and Self. Machines filling in the blanks as your body breaks down. The tissues succumbing to entropy despite the best efforts of science and technology. No one wants to end up like these poor souls who do little more than metabolize in ICU's across the country. Let their unfortunate sufferings be a lesson for our generation. Perhaps dignity and goodness can be salvaged for the future.

Sunday, December 16, 2007

Once again

I hate to be the sort of blogger who harps on the same damn thing over and over. But it happened again. 78 year old lady comes in Friday afternoon to ER with 24 hours of severe lower abdominal pain. Worse when she moves. She can't eat and vomited when they made her drink the barium for CT scan. WBC is 19,000. She's dehydrated. The CT scan is read as "ileus versus bowel obstruction." Admiited overnight to the medical attending on call. Saturday morning I get the consult. I browse through the chart, noting that my GI colleague has also been consulted. The WBC count makes me nervous so I see her as soon as I arrive at the hospital for rounds. I'm thinking SBO as I walk into the room, given the ER records and the CT read. Turns out, she has focal peritoneal signs in the RLQ and suprapubic area. "That makes it hurt all over", she says as I press on McBurney's point, exhibiting classic peritoneal signs. Moreover, she'd never had any abdominal surgery done. Adhesive obstruction would be highly unlikely. Hold on for a second, I say. Let me go look at that CT scan. I scroll through and damn if it doesn't look like appendicitis to me. Dilated tubular structure in the RLQ that doesn't seem to connect to anything else. Now, general surgeons who have come out of residency programs recently (like myself) may not be able to whip through a highly selective vagotomy, but we can certainly read abdominal CT scans. (Be aware of pompous statement coming up...) I can read a CT abdomen/Pelvis for certain diagnoses better than a lot of radiologists. With the new PACS machines, CT scans are readily viewable with a point and click. On call as a resident I'd sit up and look at all the scans that had been done in the ER, just for something to do to kill the tedium. By the time I was a senior resident I'd be catching appendicitis and going down to the ER before they even paged me. For this particular lady, I went downstairs and reviewed the scan with the in-house radiologist. He agreed. Appendicitis. At night, there's a "Nighthawk" system in place. All scans after hours are outsourced over the internet to some radiologist in Pakistan or India or Australia or whatever. (Are these guys even certified by an American Board? If not, aren't radiologists risking an awful lot in terms of liability just for a few hours of shut eye?)

Once again we have a case of a surgical problem undiagnosed until seen by the surgeon. In the meantime, multiple consultants are called to give an opinion. As a way to restrain myself from revisiting this topic over and over in a self-congratulatory fashion, I should probably at least try to diagnose the problem and provide a remedy. Appendicitis in the elderly is a notoriously difficult diagnosis, sometimes. You don't expect it. The literature shows that complications are higher in the elderly, primarily because of delayed presentation and delayed diagnosis. I get that. It's hard sometimes. But I think too often our fine colleagues down in the ER rely a little bit too much on a CT report. I understand it gets busy down there; you have no beds, you've got five patients waiting on reports, an acute MI who's not doing so well, charts to sign, a drunk frequent flyer causing a ruckus, a minor MVC in trauma bay and everything else. If the scan is positive call the surgeon, if not, admit to medicine. Formulaic. I'm right with you on that. But this lady presented with ABDOMINAL PAIN as her chief complaint. The CT scan suggested ileus/bowel obstruction but she'd never had surgery before. And her WBC was 19,000. Something was off. The clinical picture didn't correlate with the almighty CT report. Call the surgeon early, I guess is the answer. In this era of PA's and nurse practitioners, sometimes the ER attending won't lay hands on the patient. He/she listens to the story, agrees with proposed treatment plan and waits for test results to trickle back. It isn't good doctoring. I'm sorry.

I took her for lap appy that morning. Her appendix was gangrenous and perforated. I was able to finish it laparoscopically, wash everything out and leave a drain. Would she have perforated had I seen her 24 hours earlier? You never know. Today, she's doing great. WBC almost normal. Will probably go home Monday. No harm, no foul, I guess......

Saturday, December 15, 2007

SurgXperiences, 111th edition

I'll be hosting the next edition of the surgical blog carnival on December 23rd. Please submit your essays/cases before then. In the meantime, check out the 110th edition over at Cut on the Dotted Line.

Friday, December 14, 2007

Mass Health

Here's a link to the Wall St. Journal health blog detailing the cost overruns with the Massachusetts model of "universal health care". It seems doctors and hospitals are being targeted for reimbursement cuts as a way to make the bottom line look a little more palatable. I loved the comment from "Anne" at the end asking why administrators aren't asked to take cuts in reimbursement when plans implemented by said administrators go awry....


I've done four colostomy takedowns in the past 10 days. One of those weird streaks. All of them had had Hartmann's procedures done. Three had perforated diverticulitis and peritonitis and the fourth presented with an incarcerated inguinal hernia (gangrenous sigmoid colon.) The Hartmann's procedure involves doing a sigmoid colectomy and then bringing out the descending colon as an end colostomy. Patients who are sick or have a lot of fecal contamination of the peritoneal cavity are more safely treated with diversion because primary anastomoses in the pelvis are almost doomed to fail (leak) in such situations. The treatment plan is two-staged. Divert, recover from sepsis, and then bring them back in a few months for colostomy takedown. Patients are always disappointed to wake up and find they have the dreaded "bag" attached to their belly. It's understandable, of course, and you just try to reassure them that once they heal, re-establishing intestinal continuity is possible. They like to hear the word "temporary".

The problem is, not all colostomies are temporary. After Hartmann's procedures, only about 75-80% of patients are able to have the bowel reconnected. The long term effect of fecal contamination of the peritoneal cavity is severe scarring, disruption of normal tissue planes, and, often, transformation of pelvic anatomy into something unrecognizable. Colostomy takedowns are fraught with hazard. You spend over an hour sometimes just lysing adhesions and identifying what exactly the anatomy is. It's a major abdominal operation. Few cases make me as nervous. There's a disconnect between patient expectation and the reality. No matter how many times you tell the patient that the procedure is risky and could potentially make things worse, they want the "bag" to go away, no matter what. Luckily, none of the four leaked and are doing quite well......

Wednesday, December 12, 2007

Kevin Everett

Pretty cool profile on the Buffalo Bills tight end who was temporarily paralyzed duing a game earlier this season on Apparently he's walking now and is slowly regaining much of his previous strength. The ortho-spine doc who initially managed his care at the game instituted hypothermic therapy to keep his core temperature at 91 degrees. This is still a bit controversial; the level I evidence in a trauma setting simply isn't there to recommend it as a standard of care but certainly things have worked out remarkably for this young man.

Inguinal Hernia

We see a lot of referrals for inguinal hernia in private practice. Other than lap chole, inguinal hernia repair is the most common operation done in America. What people don't realize is the anatomic complexity that must be understood and navigated when undertaking the repair. Surgical residents don't really "figure out" groin hernias until sometime in the third or fourth year. It requires thinking three dimensionally in a small space. Suddenly, something clicks and everything makes sense. You could watch three colon resections and have a good handle on how to do the case, but inguinal repairs need to be watched over and over. It's very subtle.

Given that surgeons have a hard time grasping groin hernias, it's no surprise that patients struggle to articulate what is happening to them. I hear various descriptions of something going on that isn't quite right. "I got a problem 'down there'". "My ball is swollen." "Something keeps jumping out when I cough." "It pinches when I work." "Something keeps going in and out." "My doctor says I got a hernial." I've heard it all. So let's do a question and answer session and clear some things up.

What is an inguinal hernia?
Hernia comes from the Latin for "rupture". It's basically a defect in the strong fascial component of the abdominal wall. The inguinal canal contains the spermatic cord and its associated blood vessels. The testicle starts out embryologically up near the kidney. As the fetus develops, it migrates from the abdominal cavity through the abdominal wall via the inguinal canal into its final resting place in the scrotum. The membranous connection to the peritoneal cavity is called the processus vaginalis. If this remains patent, one is susceptible to indirect inguinal hernias. Indirect inguinal hernias occur lateral to the inferior epigastric vessels. Conversely, direct inguinal hernias are not congenital. They occur through attenuated tissue medial to the inferior epigastric vessels. These are the hernias of "wear and tear" and heavy lifting. Differentiating direct from indirect is not always possible pre-operatively, but the approach is the same for each one.

Why should I worry about my groin hernia?
Several reasons. Number one, you worry about bowel slipping into the hernia and getting trapped (incarcerated). This can lead to bowel obstructions and even gangrene of the affected bowel. Fixing hernias in the setting of bowel obstruction or ischemic intestine can be quite problematic and morbidity/mortality rates are substantial. So it's wise to consider repair on an elective basis; before such complications arise. Number two, hernias don't improve with time. They get worse. If you're having a hard time now, it's not going to be any better in two years.

So should all hernias be fixed?
This is a little controversial. Asymptomatic inguinal hernias can probably be watched in most men. There's a good study from the Hines VA in Chicago that addresses this. Any symptomatic groin hernia should be repaired. Symptoms can vary from patient to patient. Anything from a dull ache at the end of a work day to a sharp, acute pinch with lifting can be described. Any hernia that you see bulging yourself should be repaired. All hernias in women should be repaired. Hernias in children ought to be repaired with high ligation of the sac.

How are you going to fix my hernia?
Inguinal hernia repairs have undergone quite an evolution over the past hundred years or so. Bassini perfected a technique that still bears his name in 1887. This involved suturing the conjoint tendon/internal oblique/transversalis musculature laterally to the inguinal ligament. McVay modified the technique by adding a relaxing incision in the rectus fascia and utilizing Coopers ligament for some of the sutures. The Shouldice repair is another tissue repair that closes/reinforces the inguinal canal in four running suture layers. The problem with all of these tissue repairs, however, can be summed up in one word: Tension. Tissues brought together under tension are doomed to breakdown. Recurrence rates with tissue repairs are as high as 50-60%. Tension also substantially increases post-operative pain. Patients were often hospitalized for 4 or 5 days after hernia repair in the days prior to the use of mesh.

So you use mesh?

Absolutely. Mesh allows for tension-free repair of the defect. Tension free repairs have reduced recurrence rates to around 1-5%. Post operative pain is now manageable on an outpatient basis; 95% of patients go home the day of surgery.

Isn't mesh dangerous? What about recalls?
Mesh infection rates are usually quoted as being less than 1%. I do these operations sterilely in the OR and peri-operative antibiotics are always given. The Kugel Composix Patch was the one recalled. I never used that particular brand.

What are the kinds of mesh repairs?
There's the Lichtenstein repair, the Plug and Patch technique, and the pre-peritoneal repair. All of them involve returning any indirect sacs to the preperitoneal space and reinforcing the inguinal floor with a non-absorbable, inert mesh. For open repairs I generally utilize the Modified Millikan technique (a Robbins/Rutkow modification) using a plug inserted through the internal ring into the preperitoneal space and fixed to the internal oblique, conjoined tendon and inguinal ligament with non-absorbable sutures. The floor is then reinforced with an onlay patch.

What about laparoscopic repairs?
There are two techniques to consider when discussing the laparoscopic approach: TEPP and TAPP. TEPP stands for total extraperitoneal patch. TAPP stands for transabdominal peritoneal patch. The best way of thinking about the laparoscopic approach is to imagine a hole in your windshield. Patching that hole from the outside is comparable to what happens during an open, anterior approach. The laparoscopic approach is like fixing that hole from the inside of the car. Same end result, just a different way of approaching it. We now have good evidence that laparoscopic inguinal hernia repair is comparable to the open approach in terms of recurrence rates. Moreover, there is also accumulating evidence that patients recover much quicker with the laparoscopic approach and are able to resume activities sooner. The problem is that you have to give the patient general anesthesia for these operations. It's also more expensive.

So who do you offer laparoscopic repair to?
Recurrent hernias and bilateral hernias are the best candidates for the laparoscopic approach. You don't want to have to dissect through previously disturbed tissue planes in recurrent hernias; the laparoscopic approach allows one to address the defect through fresh, undisturbed tissue. Bilateral hernias can be fixed simulataneously through the same laparoscopic incisions without much added operative time. I also consider laparoscopic hernia repair at patients request. Young athletes who want to get back to training as soon as possible seem to bounce back quicker with the laparoscopic technique. For run of the mill, unilateral inguinal hernia, I find it hard to justify laparoscopic repair. It's costlier and cardiovascular events are certainly increased anytime you subject a patient to general anesthesia. The open approach has a low recurrnce rate, allows the patient to go home the same day, and utilizes fewer resources. That's a tough combo to ignore.

How am I going to feel afterwards?
You're going to be sore. I usually write for prescription-strength pain medications for the first three to five days. Everyone recovers a bit differently. Some guys are ready for work in three days. Others need a bit more time. Some other things to expect: scrotal swelling, numbness over the incision, burning with urination, and prickling sensations that radiate into the upper leg. Almost universally, these issues are self limited and will resolve with time.

Any restrictions afterwards?
No lifting anything more than 25 pounds for at least three weeks. Other than that I encourage resumption of normal activities as soon as possible. At six weeks, the scar tissue that forms will be about as strong as it ever will be, so until that time avoid power lifting or any similar ultra-strenuous activities.

Friday, December 7, 2007

Friday Night Relaxing

I recently acquired Sirius satellite radio and I must say: how did I use to deal with drives to and from hospitals before? Imagine being able to control your listening environment completely as you navigate traffic lights, jams and off ramps. Here's my top 5 settings:
1. Channel 32, Grateful Dead radio
2. Channel 26 Left of Center
3. Channel 35 Chill
4. Channel 72 Jazz
5. Channel 17 Jam Bands

I also listen to Jim Rome as a guilty pleasure. In general, though, listening to regular radio is barely tolerable anymore. We've entered the era of optional commercials. You don't even have to watch your favorite TV show with commercials anymore; just watch it the next day on the internet, or wait for the entire season to come out on DVD.

Anyway, there's a terrific article in the New Yorker this week by Atul Gawande. Dr Gawande is a surgeon from Harvard who is also a rather prolific writer. His books "Complications" and "Better" were best sellers. He also writes regularly for the New Yorker as a medical correspondent. Now I have to admit, a few years ago I wasn't the biggest Atul Gawande fan. I suppose I was just jealous of the dude. He is a scientist, a compassionate physician commited to excellence, and a decent man who had endured some personal tragedies. But I focused on his occasional over-earnestness and tendency toward sententiousness in his writing. He was Dr Harvard and the quintessential "academic surgeon" and I was just sick of hearing about him. But I've come around. He's genuinely an intellectually curious guy. His prose is lucid and coherent. I like his stuff.

The article this week is entitled "The Checklist" and it's mainly about the efforts of a intensivist from Washington DC named Peter Pronovost to standardize protocols of care for ICU patients. There's plenty of science to show that unsterile technique leads to higher central line infection rates. That maintaining patients on prophylactic heparin/lovenox will reduce DVT rates. That early enteral nutritional support reduces morbidity in the critically ill. What Provonost found was that most American ICU's weren't consistently following these relatively simple guidelines. His radical idea was to standardize intensivist practice via the use of clinical checklists. Each central line placed had to be done according to protocol; mask, gown, gloves, sterile drapes, chlorhexidine scrub. Nurses made sure residents and attendings followed each step. Ultimately, infection rates were reduced 66%, saving millions of dollars and countless lives. Such a simple idea; but more effective than the billions of dollars pharmaceutical companies spend each year on the development of drugs that provide marginal and sometimes dubious benefit.

The point is that medicine has become too complicated for a single person to remember all the details that ensure its safe and efficacious delivery. The idea of a checklist eliminates the possibility (hopefully) of a crucial forgotten step. All well and good. But I always get wary of medical practice than relies too much on algorithmic thinking. You have to be careful not to try and implement formulas in all areas of medical care, especially surgery. It certainly works in trauma care and the safe placement of central lines. But you don't want to lose the element of flexibility. Sometimes a particular patient won't fit into the paradigm. You could standardize the laparoscopic cholecystectomy if you wanted; mandate that each resident trainee learns the steps in an organized, checklist-type fashion such that by the time he/she graduates, the procedure proceeds without even thinking, one step naturally leading to the next in a robotic, automatic fashion. But I don't operate that way. Each case is always just a little different. Anatomy, body habitus, little quirks always seem to arise that require a bit of improvisation. Sometimes I'll put the subxiphoid port in first, other cases require the subcostal ports to be first. Sometimes you have to take the gallbladder out of the liver bed first, in order to see. I do cholangiograms most cases, but not always. I leave drains in when I feel it's warranted. Sometimes I keep the patient on Zosyn post-operatively, sometimes one dose of antibiotic is all they get. Certainly the overall goal and concept is unchanged, but the route of accomplishing it varies. Algorithmic medicine relegates patients to the status of "object"; a thing upon which to execute a process. Never forget that that body sleeping under the sterile drapes is an individual; with subtleties and variations that just may not fit into your "scheme".

Thursday, December 6, 2007


When I was a resident, all I had to do was show up at work everyday and patients would magically materialize on my list. Usually, it was annoying because longer lists meant more work. The OR schedule was usually full as we covered cases of multiple attendings. As a chief resident, it's fun; you round in the morning and then operate all day. It never really crossed my mind to think about where all these patients came from. They don't arise out of a vacuum. Someone had to be referring them to our surgeons.

General surgeons depend on primary care doctors and internists for business. We don't post ads in the newspaper or phone book. You won't see me on television touting my laparoscopic skills or announcing a year end close out on hernia repairs. The system is set up such that a patient must go through his/her PCP gatekeeper to get in contact with a surgeon. Ideally, this means that a referring doctor, using wisdom and experience, will refer a patient to the surgeon he/she trusts. And sometimes that's exactly what happens. An internist will develop a relationship and a level of trust with a specific surgeon and will refer most patients his way. But in this era of managed care and large multispecialty groups, the ideal isn't always realized. A lot of internists don't have a choice which surgeon to refer to. You simply give the patient the phone number of the surgeon in the group or the one part of the correct insurance plan, irrespective of said surgeon's capability or performance. I work in a small group that is completely independent of the two major medical behemoths in the Cleveland area so I get shut out of the patient base that is underneath those umbrellas. Every once in a while I'll take care of a patient from the Cleveland Clinic system who comes in late through the ER and I'll take out the appendix or whatever and follow up with the primary care doc over the phone, but no matter how well the patient does, or how quickly he recovers, I won't see any more patients in the future from that primary care doc because I'm simply not part of his "system". And that can be frustrating for a young general surgeon building a practice. Referral patterns, in an ideal world, would be based on surgical excellence, clinical outcomes, and personal relationships. Unfortunately, the reality is far from that. There is no absolute meritocracy in American medicine anymore. Most people's insurance plans restrict access to certain physicians. At some point, it may be necessary to join the giant group paradigm just like everyone else.

Wednesday, December 5, 2007

Retrocecal Appendix

I got called late last night by a very insistent ER Attending regarding a young gentlemen with midline suprapubic pain for a week. He had a low grade fever and apparently was having severe pain with the rectal examination. The official report from the CT scan was negative for appendicitis or any significant intra-abdominal pathology. The ER Attending, however, was convinced that this was a case of "retrocecal appendicitis" because of the severe rectal pain. Now, I get this story a lot from the ER and the there's no scientific or anatomic foundation to it whatsoever. The term "retrocecal" implies that the appendix is located retroperitoneally, behind the cecum. The only way this can happen is if the tip of the appendix is pointing superiorly toward the liver. Certainly, the presentation may be a little different from an anteromedially located appendix (back and flank pain, pain with flexion of the psoas muscle) but there would be no reason for pain elicited on rectal exam, unless there was a perforation with resultant pelvic abscess. But this ER guy was adamant. I even got the "I've seen this lots of times before; its a retrocecal appendicitis" bit. When I saw him, he was certainly tender on digital rectal exam. I reviewed the CT on my own and I thought there was a suggestion of perirectal inflammation posteriorly in the pelvis. Then when I talk to the guy I find out he's being treated with high dose Cellcept and Prednisone for Lupus. Of course, no mention of this was made to me over the phone by the ER. So he's an immunosuppressed guy with severe rectal pain and questionable inflammatory changes on the CT scan. Evolving perirectal sepsis is number one on my differential. I'll probably examine him under anesthesia in the OR later today.

Tuesday, December 4, 2007

Friday night special

The last case of the day Friday was a classic. She was an 80 year old lady who'd been suffering from biliary colic for a number of years who finally decided to have her gallbladder taken out. Preoperative liver function tests were normal, but there was a suggestion of mild intrahepatic biliary dilatation on the CT scan. I repeated the LFT's in a week and, again, they were normal. So we prepared for laproscopic cholecystectomy. The gallbladder was jam pack full of hard stones and it was difficult to get a good grip on the fundus. There were a lot of dense adhesions, but I went slow, teasing away the tissue strand by strand. I identified a thin tubular structure coming out of what appeared to be the distal infundibulum of the gallbladder. I made a nick and inserted my cholangiocatheter. Under fluoroscopy, the dye seemed to flow easily into the duodenum but I couldn't get the proximal ducts to opacify. Based on the cholangiogram, one would have to conclude one was in the common duct. So I pulled out the cholangiocatheter and started to work a bit more on the dissection. There was a giant stone in the infundibulum, which made retraction suboptimal, but I was able to free things up a bit more and I thought I saw another ductal structure posteriorly. This is where the anal sphincter tightens up a bit. With retraction, the stone in the distal infundibulum started to break through the wall and it wasn't clear to me where the cystic duct was at this point. So I opened. I took the gallbladder down and it became apparent that there was a ping pong ball-sized stone lodged 1/2 in the common duct, 1/2 in the distal infundibulum. There was no cystic duct. I cut across the distal gall bladder and popped out the stone, leaving me with a fairly good sized defect in the lateral common duct. I closed the cholangiocather site with a single stitch of 3-0 PDS. Then I closed the common duct transversely around a 14f T-tube. A Jackson-Pratt drain was placed and I got out of Dodge. The intraoperative cholangiogram through the T-tube showed.... normal filling of all the intrahepatic radicles. Currently, she's doing great. LFT's are normal. No bile in the JP. I clamped off the T-tube. Plan for T-tube cholangiogram in 6 weeks.

The lesson in this case was: Trust Your Cholangiogram. Misinterpretation of a cholangiogram is one of the leading causes of severe biliary injury during lap chole. It isn't enough to simply "do the cholangiogram in the standard fashion." Think about what you see. It would have been easy to attribute nonfilling of the right and left ducts to a wide open sphincter of Oddi and just finishing the case. Especially on a Friday night. If the pictures you're receiving on the cholangiogram don't correspond to the mental image you have about what the anatomy is, then further investigation is necessary. You don't want to end up with this.