We are in the midst of a laparoscopy explosion in general surgery. Two articles relate to some problem areas of this technique. The first, by Berguer and colleagues, is an ergonomic study of the labor or physical effort required for laparoscopic maneuvering as opposed to an open procedure in the art of knot tying. They concluded that complex manipulative tasks using laparoscopic instrumentation require substantially higher upper extremity muscle effort compared with open surgery. This increased workload is often accompanied by an increase in the subjective discomfort of the surgeon in the affected areas—food for thought.
Second, Podnos and colleagues have reviewed the literature regarding the complications after laparoscopic gastric bypass (3464 cases). They found that the type and frequency of postoperative complications after laparoscopic and open gastric bypass are different. Laparoscopic operations were associated with a higher frequency of early and late bowel obstruction, gastrointestinal hemorrhage, and stomal stenosis, whereas the open bypass was plagued by iatrogenic splenectomy, wound infection, incisional hernia, and mortality. The authors believe that part of the difference regarding laparoscopy is related to the learning curve of this complex procedure. This article provides an interesting analysis.
Another interesting concept is seen in the work of Vila and colleagues who studied the comparative outcome of procedures performed in physicians' offices as opposed to ambulatory surgery centers. They found an approximately 10-fold increased risk of adverse incidents and death in the office setting.
This team from the University of California, Los Angeles, describes a consecutive series of 55 patients undergoing Whipple procedures for ampullary adenocarcinoma from 1998 through 2001. They demonstrate an improved survival of 10% to 20%, perhaps related in part to adjuvant treatment. The major factor associated with prolonged survival was the absence of perineural invasion in the resected tumor specimen.
Always alert to new methods of ruling out operation for patients with pancreatic cancer that has spread beyond areas of resection, this group from the University of California, Davis, noted a correlation between high serum levels of CA19-9 and unresectable disease in 89 patients. The authors suggest that patients with high levels of this antigen might benefit from additional staging modalities such as diagnostic laparoscopy to avoid unnecessary laparotomy.
A good deal of discussion was prompted by the introduction of physician assistants into a plan to create a positive effect on graduate medical education and resident hours and activities. This group at the University of California, San Francisco–East Bay found that physician assistants can positively influence all aspects of resident work and education.
This Month in Archives of Surgery. Arch Surg. 2003;138(9):939. doi:10.1001/archsurg.138.9.939