April 2022 Print issue by McMahon Group

GENERAL SURGERY NEWS The Independent Monthly Newspaper for the General Surgeon

GeneralSurgeryNews.com

April 2022 • Volume 49 • Number 4

MONEY MATTERS

Beyond Your First Contract Networking Is Key for Active Job Seekers ers

Late Guidance on Elective Latest Surgery in COVID-19 Patients Released

By MONICA J. SMITH By CHRISTINA FRANGOU

he primary reason that surgeons report leavaving a position is inadequate compensation. But taken with the other four leading causes (e.g., poor oor work‒life balance, job does not meet expectations), ns), the main reasons can be summed up largely in one sentence. “They don’t get paid enough to put up with this,” said Steven Chen, MD, the director of sururgical oncology at OasisMD in San Diego, duringg a session on assessing and negotiating job opportunities at the 2021 virtual American College of Surgeons Clinical Congress (PS346).

For surgeons, sometimes a busy call schedule, ule,

he American Society of Anesthesiologists and Anesthesia Patient Safety Foundation have released an updated upd statement on the timing of elective surgery in patients pati recovering from COVID-19. In I the guidance, the two organizations recommend that elective elec surgery be delayed for seven weeks after a SARSCoV-2 CoV infection in unvaccinated patients. There is insufficient ficie evidence to make recommendations for vaccinated patients pati who become infected with COVID-19, the societies etie concluded. “Although “A there is evidence that, in general, vaccination reduces redu post-infection morbidity, the effect of vaccination on the appropriate length of time between infection and surgery/procedure surg is unknown,” according to the statement.

Continued on page ge 14

Continued on page 10

Assessing Need for a Change

Expert Panel Advises on Preventing SSIs After Colorectal Surgery

OPINION

The Occult Inguinal Hernia

Grandfather Did It

By ALISON McCOOK

By EDWARD L. FELIX, MD

panel of 15 colorectal surgeons compiled a set of recommendations for how to prevent surgical site infections, based on their expert opinion and review of dozens of studies. The recommendations include advice on what to use, what lacks sufficient evidence to support its use, and nuanced approaches to wound irrigation and the location of incisions (J Am Coll Surg 2022;234[1]:1-11). According to a 2020 study, 23.9% of patients develop an SSI after colorectal cancer surgery, which can cost commercial payors up to $145,000, and $102,000 to Medicare within a year (Dis Colon Rectum 2020;63[12]:1628-1638).

ince the COVID-19 lockdown own and my subsequent retirerement from the OR, I have spent nt too much time in my easy chair air contemplating the state of inguiuinal hernia repair instead of hididing out in the OR repairing them. It has been fun, however, rethinking my opinions on robotic surgery as expressed in two previous opinion pieces in General Surgery News [“Robotic Surgery: Déjà Vu All Over Again,” March Continued on page 18

Continued on page 22

IN THE NEWS

4 Southeastern Surgical Congress Highlights Book Series for Children Having Surgery J OURNAL WATCH

16 Topics: COVID-19; Sigmoid Cancer; Gallstone Pancreatitis; Inguinal Hernia

Advanced Surgical Energy—Clinical Experience With the POWERSEAL™ Sealer/ Divider Curved Jaw, Double-Action PAGE 12

facebook.com/generalsurgerynews

hen it was discovered that at Kamila Valieva, the mag-nificent 15-year-old ice skat-er competing for the Russian n Olympic Committee (ROC), had ad taken trimetazidine (a fatty acid d metabolism blocker and carbohydrate utilization accelerator), a performance-enhancing drug banned by the Olympics, the ROC blamed it on a drug her grandfather was taking. The ROC, the head Russian skating coach Eteri Tutberidze, and the athlete did not accept responsibility for the violation. The grandfather was somehow responsible for her use of his

Continued on page 14

6 New Surgeon-Only Networking App;

By HENRY BUCHWALD, MD, PhD

To Fix or Not to Fix? That Is the Question

@gensurgnews

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OPINION

APRIL 2022 / GENERAL SURGERY NEWS

Remembrances Past and Present By FREDERICK L. GREENE, MD

n my January 2022 editorial in this publlication, “More Than CME,” I highlighted the 30th anniversary of the destruction of the Berlin Wall in 1989, celebrated a few months previously in November 2019. As a meeting goer in Berlin in 1988, I had the unique opportunity of traversing “Checkpoint Charlie“ and experiencing firsthand the somberness of East Berlin under the autocratic rule of the Soviet Union (U.S.S.R.). Two years later, in the fall of 1990, as a member of a “People to People” mission populated by colleagues with primary interests in cancer care, I was able to visit the U.S.S.R. itself as it began to crumble. We were not just tourists, but were invited as guests of the Soviet republic and its oncology community. Beginning in Moscow, our group traveled for the next three weeks to many cities in the U.S.S.R., meeting Soviet physicians, giving lectures, and touring facilities offering oncologic care. We were struck by the depressing state of medical care and, of course, had no inkling that the entire U.S.S.R. would disintegrate in the following year! One of our stops was Kyiv, in The Ukraine (now just Ukraine), where we spent several days touring the city and meeting the people. We, of course, were well aware that Chernobyl, the site of a massive nuclear accident four years before our visit, was only 60 miles away. Despite our interest in the site as potentially a major cause of several forms of malignancy, we were not allowed to

Senior Medical Adviser Frederick L. Greene, MD Charlotte, NC

Editorial Advisory Board Gina Adrales, MD, MPH Baltimore, MD Maurice Arregui, MD Indianapolis, IN Philip S. Barie, MD, MBA New York, NY L.D. Britt, MD, MPH Norfolk, VA James Forrest Calland, MD Charlottesville, VA David Earle, MD Lowell, MA Sharmila Dissanaike, MD Lubbock, TX Edward Felix, MD Pismo Beach, CA Robert J. Fitzgibbons Jr., MD Omaha, NE Michael Goldfarb, MD Long Branch, NJ Leo A. Gordon, MD Los Angeles, CA

visit the area and were restricted to institutions in Kyiv. The streets of Kyiv were quite beautiful and lined with massive buildings, especially in the central part of the city. The people were eager to use their English and were delighted to ask about anything American. There was a definite difference in the temperament and approachability that characterized the people—medical and nonmedical—that we encountered in Kyiv as compared with those individuals we met previously in Moscow and later in Leningrad. Perhaps this was a signal of later things to come for the Ukrainians! Our final few days were spent in Leningrad, later to be renamed to the original St. Peters- Independence Square in Kyiv, Ukraine, in 1990. burg. We visited the Petrov Cancer Institute Source: Wikimedia Commons and had time for seeing the magnificent sites that were still reminiscent of Czarist Russia. After stop- especially the Baltic countries and the NATO alliance. I ping for a couple of days in Helsinki, Finland, we flew am praying that our Ukrainian medical colleagues, whom back home and later spent time critiquing our experiences we met over 30 years ago, and their families are safe. As and pondered about the fate of the U.S.S.R. in the future. I have watched the destruction in Kyiv and other citWe did not have long to wait. Within a year, under the ies in Ukraine, I have frequently relived those few days leadership of Boris Yeltsin, the Soviet republic disinte- in 1990, that my oncology colleagues and I walked the grated into Russia and several Baltic states, but the region streets and met the people. For many of us in medicine, known as The Ukraine remained under Russian rule for the opportunities to visit and network with internationa time until gaining independence years later. al colleagues have been precious. These remembrances We have all watched with horror over the last two manage to always stay with us. ■ months as the sovereignty and very existence of Ukraine have been threatened. The wanton invasion by Russia —Dr. Greene is the senior medical adviser for has created another devastating moment for Europe and General Surgery News.

Jarrod Kaufman, MD Brick, NJ

MISSION STATEMENT OF GSN It is the mission of General Surgery News to be an independent and reliable source of news and analysis about the current state of surgery. It strives to provide a venue for discussion and opinions, from all viewpoints, on the issues most important to surgeons. DISCLAIMER Opinions and statements published in General Surgery

Peter K. Kim, MD Bronx, NY

News are of the individual author or speaker and do not represent the views of the editorial advisory board, editorial staff or reporters.

Lauren A. Kosinski, MD Chestertown, MD

DISCLOSURE POLICY We endeavor to obtain relevant financial

Marina Kurian, MD New York, NY

disclosures from all interviewees and rely on our sources to accurately provide this information, which we believe can be important in evaluating the research discussed in this publication.

Raymond J. Lanzafame, MD, MBA Rochester, NY

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IN THE NEWS

FIRST LOOK

GENERAL SURGERY NEWS / APRIL 2022

The Southeastern Surgical Congress All Articles by MONICA J. SMITH

Lower-Pressure Pneumoperitoneum Decreases Post-op Pain

When Fragmentation of Care May Be Better: Treating Pancreatic Cancer

NASHVILLE, Tenn.—The carbon dioxide insufflation used in laparoscopic surgery to create pneumoperitoneum is associated with some challenging metabolic changes and can cause pain. New research suggests low-pressure pneumoperitoneum reduces postoperative pain, with other positive outcomes. As part of a quality improvement program at the University of South Alabama Medical Center, in Mobile, researchers who had been performing laparoscopic procedures with standard pressure, at 15 mm Hg, wanted to find out if they could complete cases at a lower pressure of 8 to 12 mm Hg. g. “Our cases varied from genereral surgery and foregut surgery;; our primary outcomes included post-op pain scores and morphine milligram equivalents (MMEs) at discharge or 24 hours after surgery, whichever came first,” said John Paul Saway, a second-year medical stu-dent presenting on behalf of his co-authors at the 2022 Southeastern Surgical Congress. The investigators’ secondary outcomes included operating times, intraoperative peak inspiratory pressure, end-tidal carbon dioxide (EtCO2) and the need to convert to standard pressure. The results showed that “there was significantly less consumption of MMEs in the low-pressure group, at 11.7 compared with 17.4 in the high-pressure group. In addition, we see that many of the low-pressure patients had an MME score of zero,” Mr. Saway said. In addition, a significantly decreased peak inspiratory pressure value was observed in the low-pressure group, at 24.7 compared with 31.4 in the high-pressure group, and EtCO2 levels also were lower in the low-pressure group. “The question then becomes what factors contribute to completing cases at 8 mm Hg?” Mr. Saway said. He noted that his institution uses two different insufflation systems—constant mode and demand mode— both of which are available in all operating rooms. All of the cases using low pressure and constant mode were able to be completed at 8 to 12 mm Hg, whereas 17% of the low-pressure cases using demand mode needed to be increased to standard pressure. “Looking at the 8-mm Hg group alone, 58% of cases were able to be completed in constant mode compared with only a third of demand mode cases at 8 mm Hg,” Mr. Saway said. In addition, with demand mode, surgeons needed to increase the pressure with heavier patients, but constant mode was able to handle a wider range in body mass index, up to 60 kg/m2, with no patients needing to be converted to 15 mm Hg. “Overall, we saw that the constant insufflation system improves visualization throughout the procedure and increases the ability to perform more procedures at 8 mm Hg,” Mr. Saway said.

NASHVILLE, Tenn.—Fragmentation of care is often associated with disadvantaged populations and poorer healthcare outcomes. Paradoxically, a recent study found better survival in pancreatic cancer patients who sought treatment at multiple institutions. “The care of pancreatic cancer patients involves coordination of specialized multidisciplinary providers and involves multimodal therapy, including surgical resection and chemotherapy,” said Victoria Bouillon, MD, a general surgery resident at the University of South Alabama Medical Center, in Mobile, at the 2022 Southeastern Surgical Congress. easter But surgeons who have the expertise to provide tthese operations are not everywhere, requiring patients to travel for adequate surgical resections. Dr. Bouillon and her colleagues conducted a study to identify patient factors predictive of fragmentation of care, and to assess how this fragmentation affects overall survival in pancreatic cancer. Using the National Cancer Database, they identified 20,013 patients diagnosed with noniden metastatic pancreatic ductal adenocarcinoma between 2005 and 2016. Of those, 4,822 (24%) received fragmented care, while 15,191 (75%) underwent all of their oncologic care at a single institution. “We saw a statistically significant increased rate of fragmented care amongst younger patients (under 80), amongst nonminority white patients and amongst patients in the Northeast and Midwest,” Dr. Bouillon said, noting also a statistically increased rate of fragmented care in patients with fewer comorbidities, higher socioeconomic status and private insurance. “We also saw a statistically significant increased rate of fragmentation amongst patients who had advanced stage disease, amongst those who received care at academic centers, and amongst those who received care at high-volume centers,” she said. A multivariable analysis showed most of those associations remained independent associations—less fragmentation among older and minority patients, and more fragmentation in patients in the Northeast and Midwest. Looking at 30-day, 90-day and overall survival, Dr. Bouillon and her colleagues found decreased mortality at 30 and 90 days and a 10% improvement in overall survival in patients who received fragmented care. The study was done on a national level, but Dr. Bouillon scaled it down to the state level, showing how fragmentation may come about. In Alabama, although medical oncologists are distributed evenly throughout the state, only three counties have surgeons trained to perform the types of resections needed to treat pancreatic ductal adenocarcinoma. “So, patients likely have to travel farther distances for their pancreatic resections while they have the option to receive chemotherapy at home,” she said. Dr. Bouillon acknowledged the study’s limitations: using only the National Cancer Database, which accepts data on patients only from Commission on

Cancer–accredited centers, and having no data on travel or recurrence rates. But their study suggests that fragmented care in pancreatic cancer may indicate higher access to care and confer a protective effect.

Obesity Ups Survival in Esophageal Cancer Patients Undergoing Robotic Surgery NASHVILLE, Tenn.—Obese patients who undergo robotic transhiatal esophagectomy for esophageal adenocarcinoma have longer operating times, but their weight appears to have no impact on other surgical variables and they have longer survival than underweight patients, according to the results of a new study. “Esophagectomy is the cornerstone treatment for patients with esophageal adenocarcinoma, and there have been conflicting results regarding the association between body mass index and postoperative outcomes. The impact of BMI after robotic esophagectomy has hardly been studied,” said Harel Jacoby, MD, a surgical fellow at the AdventHealth Digestive Health Institute Tampa, in Florida, with Sharona Ross, MD; Iswanto Sucandy, MD; and Alex Rosemurgy, MD. To investigate the impact of BMI on postoperative outcomes in patients undergoing robotic transhiatal esophagectomy (THE) and determine the relationship between BMI and long-term survival, Dr. Jacoby and his colleagues prospectively reviewed patients undergoing the procedure between 2012 and 2020. The study included 71 patients with a mean BMI of 27+4.9 kg/m2; most patients (72%) received neoadjuvant chemoradiation. The operations in overweight and obese patients took longer than those in normal-weight and underweight patients (five to six hours compared with four to five hours), but there was no difference in conversion to open, lymph node harvest, tumor size, stage or blood loss. Twelve patients experienced major postoperative complications; five died in the hospital; the median length of stay was seven days; and the readmission rate was 18%. But again, none of these variables were associated with BMI. Dr. Jacoby noted that three of the five deaths occurred in heavy smokers with severe chronic obstructive pulmonary disease. “Looking only at 30-day mortality, two patients died, or 2.7%, which is similar to what we see in the literature. Also, mortality was more common early on, reflecting the learning curve,” Dr. Jacoby said. Median survival was not reached (the probability of survival is 67% at 97 months), but the five-year survival rate for obese patients was 93% compared with 33% of underweight patients (P=0.05). “Obesity does not affect short-term outcomes following robotic THE, but favorably affects long-term survival. The robotic platform is a great way to handle complex abdominal procedures, and we believe it will take a greater role in the near future,” Dr. Jacoby said. ■

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IN THE NEWS

GENERAL SURGERY NEWS / APRIL 2022

New Surgeon-Only App Offers Networking, Educational Opportunities social space, respecting the beauty that’s created when you collaborate with peoooking for a secure way to network ple online,” Dr. Soliman said. The platform has alleviated privacy with fellow surgeons online? Need to find a high-quality video of a robotic issues while at the same time preventWhipple? Want to attend an education- ing trolls from hiding behind an anonal webinar with live discussion? Curious ymous handle, by verifying that every what surgeons in various subspecialties person who joins the platform is a surare working on? There’s an app for that. geon based on their national practitioner Agnostic to specialty and modali- identifier (NPI) number. Although this ty, SurgeOn (surgeonapp.com) is a free, limits SurgeOn to U.S. surgeons for now, surgeon-only networking application Dr. Soliman’s team plans to launch an international platform that will include built to solve the problems associated non-NPI verification, opening up with other online social networks. ks. non the platform to residents and stu“Right now, most surgeons ns dents who do not yet have NPIs. either don’t have a home to con-de “[This way,] you know the nect virtually or they use pub-qualifications of every person lic social media sites. Those aree qu you’re communicating with in great in their own merit, butt y the application,” Dr. Soliman they have tremendous limitasaid. tions, such as privacy conTo protect against the risk cerns, security concerns, and for surgeon data being brodiscoverability issues that have led to litigation,” said Mark Soliman, MD kered and sold—the way other social media sites use Mark Soliman, MD, a colon and rectal surgeon with AdventHealth member data—SurgeOn simply doesn’t Medical Group Colorectal Surgery, in collect it. “We refuse to collect certain aspects of Altamonte Springs, Fla. “We’ve looked at each of these prob- data. There’s nothing that we could sell lems from a 30,000-foot view and tried to brokers or lenders, and nothing that to solve them in a way that’s congruent could be stolen,” he said. As a platform created by surgeons with how we want to be treated in the By MONICA J. SMITH

The SurgeOn app offers an array of educational and networking opportunities for surgeons, including videos of procedures, webinars with live discussion and the ability to discuss challenging cases.

Resident Creates Book Series for Children Having Surgery An Easy-to-Understand Guide for Kids and Their Parents “There was one book, about appendicitis, with real-life photos that dic I found far from friendly. So, I aria Baimas-George, MD, MPH, H, thought, it may be fun to create my thought she’d become an author some-th own books and that’s how this side day. She had been writing since she was old d o hustle began.” enough to hold a pencil. In college, her path h To date, her series titled “The turned to medicine, but she has found a way to Strength of My Scars: Pediatric combine her two passions: writing books for Surgical Chronicles,” includes children that explain surgical and medical 21 books intended to help chilsituations in a language they, and their pardren understand basic anatomy, ents, can understand. know what to expect of proceDuring her first year of residency, Dr. Maria BaimasGeorge, MD, MPH dures and recovery, and learn Baimas-George noticed that communiwhat type of healthcare workcations between doctors and patients and their parents in the pediatric surgery and pediatric ers they might encounter. The books are also illustrated by the author with wateroncology services were often subpar. “These are high-stress, high-anxiety moments. Even color paintings that depict a variety of when people have a background in healthcare, it can be patients and providers. difficult for them to understand what’s going on,” said Dr. Baimas-George, a fourth-year surgical resident at Caroli- They’re Not Just Charming; They Work nas Medical Center, Atrium Health, in Charlotte, N.C. She also believed there was a lack of child-specifWith the first couple of books under her ic resources. “We often explain our treatment plans to arm, Dr. Baimas-George started querying caregivers and kids in the same waywhich is far from publishers. Although feedback was posiideal—creating confusion, anxiety and misunderstand- tive, none believed that titles like “Pyloric ing,” Dr. Baimas-George said. Stenosis: That Time My Stomach Flexed” She did some research, but was unable to find read- would find a place in their market. ing materials specifically geared toward children facing “So, I went to my chairman of surgery, operations or dealing with other medical issues. Dr. Brent Matthews, who suggested I apply By MONICA J. SMITH

Books from the series “The Strength of My Scars,” by Maria Baimas-George, MD.

for a research grant to study whether these books have a real benefit,” Dr. Baimas-George said. This request was successful. Earning a grant from the Department of Surgery’s academic enrichment fund, Dr. Baimas-George and her colleagues randomized the caregivers of 80 children with a diagnosis of uncomplicated appendicitis, ruptured appendicitis, pyloric stenosis, need for gastrostomy tube or umbilical hernia to receive her eeducational book or not receive one. The “after” surveys indicated significant improvements in 14 of 17 n questions that addressed compreq hension, satisfaction and appreh hension in the experimental group h compared with the control group. The study will be published in an issue of the Journal of the American College of Surgery, and Dr. BaimasGeorge presented it at the American Pediatric Surgical Association conference last May.

IN THE NEWS

APRIL 2022 / GENERAL SURGERY NEWS

exclusively for surgeons, SurgeOn is unique among physician-oriented social networking platforms. “Surgeons know what surgeons need,

Expanding the Shelves The successful outcome of her research encouraged Dr. Baimas-George to continue writing her books. She plans to do at least 60. Having finished the surgical books, she is now drawing on the expertise of colleagues in other specialties to tackle less familiar situations. “I recently completed a book on broken bones and had great help from some orthopedic surgery colleagues to ensure all my facts were correct. As I venture out of general surgery and topics I know more intimately, the books take me a bit longer, but as long as they may help kids, it’s well worth it,” Dr. Baimas-George said. How does a resident working 80 hours per week and applying for a fellowship in transplant surgery find the time? She often swaps television watching for finishing a book. “Honestly, I really enjoy making them. It doesn’t feel like work. Working on these books has become a way for me to relax by changing up my routine a little bit,” she noted. For more information or to order a book, visit www.strengthofmyscars.com. ■

such as a categorizable video library. We know that we tremendously value the feedback of our fellow surgeons when it comes to specific videos, specific steps of an operation, so we built in voting algorithms—basically a Likert scale,” Dr. Soliman said. While protecting its members’ privacy from people outside the surgical community, the app allows surgeons to explore other specialties and learn more about their colleagues and what they do. “A general surgeon can easily wander into a cardiothoracic surgeon community, look at their videos and posts and

application, Dr. Soliman said. comment, or into a uroloThe team has a laundry list of gy community or gynecolitems in development, such as ogy community. The ability surgical society integration to discover other commuand an events section. nities and commune with “Where you see SurgeOn other people is a big deal right now is not where you’re in the surgical space. You Scan code for direct going to see it in three weeks, get to see what’s happening link to SurgeOn app three months or three years. in other quadrants of the There is nothing we want more than to abdomen. This is the essence of multidistruly unify all of surgery under one roof,” ciplinary collaboration” Dr. Soliman said. Dr. Soliman noted. Launched in August 2021, SurgeOn SurgeOn is available as a free downcurrently has about 1,000 members and contains the features any social media load in the Apple App Store and Google user would expect to find opening an Play Store (surgeonapp.com/share). ■

IN THE NEWS

GENERAL SURGERY NEWS / APRIL 2022

Female Patients More Likely to Fare Worse When Operated on by Men, Large Study Shows By CHRISTINA FRANGOU

emale patients are more likely to experience adverse outcomes when they are operated on by a male surgeon than a female one, according to a Canadian study of more than 1.3 million patients. The study, published in JAMA Surgery, examined sex concordance between surgeons and patients, and found female patients treated by male surgeons were 32% more likely to die and 15% more likely to have a complication than those treated by female surgeons (JAMA Surg 2022;157[2]:146-156). A similar pattern was not seen for male patients. They fared as well or better when they had a female surgeon, the study showed. Investigators said it is unclear what is causing this pattern but called for deeper examination of underlying factors. “Perhaps there’s something different that women are doing from men across the board, and that might exist before surgery and after surgery, which are key periods that are sometimes not given enough focus when it comes to making decisions about taking risks at the right time,” said study co-author Angela Jerath, MD, an anesthesiologist at Sunnybrook Health Sciences Centre and an associate professor at the University of Toronto. The pattern was consistent across 21 different operations and multiple surgical subspecialties studied. Surgeons who reviewed the paper said even without a full understanding of the reasons for the disparity, the finding highlights the need for more women in the surgical workforce. “The association between surgeon‒ patient sex discordance and outcomes sounds the alarm for urgent action,” wrote surgeons Andrea N. Riner, MD, MPH, and Amalia Cochran, MD, FACS, FCCM, of the University of Florida, in Gainesville, in an invited commentary. Calling the findings “troubling,” they said action should be taken immediately to address a lack of female surgeons. Andrew S. Wright, MD, the Center for VideoEndoscopic Surgery Endowed Professor at the University of Washington, in Seattle, said surgery as a profession must be committed to investigating the reasons why women treated by male surgeons have worse outcomes. He believes there are likely several factors, including too few surgeons of all genders in the profession. “It sends a signal that perhaps male physicians or male surgeons are less attuned to or sensitive to women’s health issues, that we may listen to symptoms and concerns of women less,” he said. “And that I

think that it is a real wake-up call.” Historically, women entering surgery had to overcome more barriers and perform better to attain the same positions as men—which could also be a factor in their better outcomes, Dr. Wright said. The study builds on an earlier report in the British Medical Journal (2017;359:4366), led by the same authors from the University of Toronto,

that showed female surgeons had better patient outcomes than male surgeons. To follow up on the 2017 study, the investigators examined outcomes in patients undergoing operations in Ontario’s public health system between 2007 and 2019. Investigators controlled for variables such as patient age, type of surgery, comorbidities, and surgeon volume and years in practice.

The study included 1.32 million patients who were treated by 2,937 surgeons. In all, 82% of surgeons were male and 18% were female. Female surgeons were younger and had lower annual surgical volumes than their male colleagues. Investigators said they could not account for case complexity, but noted that no evidence indicated male surgeons were performing on more complex

L I

‘The real task now is to … find the cause of the association seen. Is it poor communication? Implicit bias? Is it the same cause in different hospitals and geographic areas? And importantly, what outcomes in this equation matter to the patient? ’ —Deborah S. Keller, MS, MD

IN THE NEWS

subsets for each procedure. The study found female patients treated by a male surgeon had an 11% increase in the likelihood of readmission, compared with having the same procedure done by a female surgeon. A large body of research suggests physicians, especially male physicians, underappreciate the severity of symptoms in female patients, said the authors. At the same time, patients are also less likely to report postoperative pain to male assessors. Other studies have shown sex discordance between surgeons and patients may lead to incomplete examinations in

the postoperative setting. Together, these factors may add up to worse outcomes for female patients, according to the authors. “These issues may contribute to a failure to rescue when patients have minor deviations from expected postoperative pathways,” wrote Dr. Jerath and coauthor Christopher J.D. Wallis, MD, PhD, an assistant professor of urology, Department of Surgery, University of Toronto and Mount Sinai Hospital. Amir Ghaferi, MD, the Moses Gunn, M.D. Professor of Surgery at the University of Michigan Medical School, in Ann Arbor, has studied factors that contribute to failure to rescue. It’s rarely about technical skill, and more often about how postoperative teams rally to identify and manage complications appropriately, he said. “Diverse teams—whether that’s gender diversity, racial, ethnic diversity or a combination—perform better and are higher functioning,” Dr. Ghaferi said. “This [study], to me, further strengthens that narrative in a healthcare setting.” The study attracted much attention, with stories in the lay press and comments from surgeons and patients on social media. Most of the response from surgeons has focused on the need to attract and retain more women in surgery. “This provocative report adds to the body of literature indicating that diversity in the workforce is better for organizational success, patient care and health disparities,” said Carmen Solórzano, MD, the chair of surgery and the John L. Sawyers professor of surgery at Vanderbilt University Medical Center, in Nashville, Tenn. According to Dr. Solórzano, women take more time with their patients and shoulder a disproportionate amount of nonprofessional duties like child care and household responsibilities. To retain women, workplaces need to adopt policies that create more supportive environments, she said. “As a leader in surgery, I know we must move faster to provide women surgeons with work environments that are respectful, flexible, inclusive, with fair advancement opportunities and pay. This is the only way we will see benefit for all,” Dr. Solórzano said. In 2019, only 22% of general surgeons in the United States were women, with orthopedic surgery having the lowest representation of female surgeons at 5.8%. The study authors also called on surgeons treating patients who are not of the same sex to remain diligent and sensitive to patient needs and the potential for implicit bias. “What we can do is just be more alert, more prudent, get the right people involved at the right time to give patients the best shot if they do run into issues,” Dr. Jerath said. continued on page 17

IN THE NEWS

GENERAL SURGERY NEWS / APRIL 2022

Elective Surgery and COVID-19 continued from page 1

The guidance is based on research from earlier waves of the pandemic indicating that patients who underwent elective surgery within the first six weeks after COVID-19 had higher rates of mortality than those whose procedures were delayed. At the time of the studies, COVID-19 vaccines were not available. The guidance, published by the two societies on Feb. 22, is intended to aid hospitals, surgeons, anesthesiologists and proceduralists in evaluating and scheduling surgical patients. The groups’ previous guideline, published in March 2021, called for all nonurgent procedures to be delayed until patients with a recent COVID-19 infection met the criteria to discontinue isolation and had entered the recovery phase. The organizations noted that very limited data were available on surgical outcomes after a COVID-19 infection, but suggested waiting four to 12 weeks between COVID-19 diagnosis and surgery, depending on the severity of a patient’s illness. “The purpose of these statements is really to provide a decision aid for difficult healthcare scenarios. It’s not

necessarily a standard, but [addresses] challenges that clinicians are faced with,” said Daniel Cole, MD, the president of the APSF and a past president of the ASA. Dr. Cole is an anesthesiologist at University of California, Los Angeles. He said the societies decided to update the recommendations in light of new evidence and questions from clinicians about potential risks after surgery with the omicron variant. No significant studies to date have addressed the risk for postoperative complications or mortality in patients who had a recent infection with the omicron variant. The organizations choose to be cautious in their recommendations, Dr. Cole said. “The question becomes, with an incomplete set of data, where do you want to make the error? Do you want to make it on being too conservative and minimizing risk, or being too liberal as far as doing surgery and potentially increasing risk? If it were a member of my family for an elective surgery that there was no harm to me or my family by waiting seven weeks, I would wait seven weeks,” he said.

Overall, both societies recommend that elective operations be performed in patients after COVID-19 infection only when anesthesiologists and surgeons agree to jointly proceed with an operation. The decision to operate should be based on a patient’s infectious status and take into account the potential risks of proceeding with surgery versus further delaying an operation, according to the statement. The updated recommendations are based on evidence that emerged over the last year. One study from the CovidSurg Collaborative, published in the journal Anaesthesia, examined outcomes for

140,231 patients from 116 countries who underwent emergency or elective surgery in October 2020. In an adjusted model, there was a significantly higher risk for 30-day mortality in patients with a preoperative COVID-19 infection diagnosed in the six weeks before surgery compared with patients who did not have an infection (Anaesthesia 2021;76[6]:748-758). In the United States, a study of 5,479 patients who underwent major elective surgery after SARS-CoV-2 infection revealed that surgery within zero to four weeks of infection was associated with an increased risk for postoperative complications (Ann Surg 2022;275[2]:242246). When surgery was postponed four

The Scientific Greats: A Series of Drawings

Wilhelm Conrad Röntgen (1845-1923) unique uses outside the medical field as well, such as airport security, studying fossils, and for inspectever in the history of medicine, one could ing food products, to name only a few. argue, has there been a discovery as signifThe discovery by Röntgen, in combination with icant as the x-ray. The achievement, realized on Marie Curie’s discovery of radioactivity, would Nov. 8, 1895, earned Wilhelm Conrad Röntgen open the door to the first use of diagnostic x-rays the first Nobel Prize in Physics in 1901. For the in 1896, which reduced the need for dangerous first time in human history, the interior of the body exploratory surgery to find cancerous lesions and could be seen in a living person. It could be said other medical conditions. Within a month of pubthat Professor Röntgen had a “happy accident.” lishing the discovery of the x-rays, radiographs were Wilhelm Röntgen,a professor of physics in Wurzbeing produced in the United States and Europe. burg, Germany, serendipitously discovered the x-ray One of the first Americans to use this new techin 1895, while testing whether cathode rays could nology was a Chicago homeopathic medical student named Emil Grubbe, who became the world’s pass through glass. His cathode tube was covered first radiation oncologist when he used x-rays to in heavy black paper, so he was surprised when an irradiate a patient with breast cancer. Unaware of incandescent green light escaped and projected onto the associated dangers, Grubbe developed radiation a nearby plate covered with barium platino-cyanide. dermatitis and multiple cutaneous malignancies. Through experimentation, he found the mysterious light would pass through most substances while Before the discovery of the x-ray, an exploratoleaving shadows of solid objects. Because he did ry laparotomy was considered a diagnostic tool for an not know what the rays were, he called them “X,” a unknown cause of disease or for the treatment of acute mathematical designation meaning “unknown” rays. trauma. With the discovery of the new technology In the following weeks, Röntgen ate and slept in and its significant improvements in subsequent years, Wilhelm Conrad Röntgen (1845-1923) his laboratory as he investigated many properties the trend for surgical exploration decreased gradually. 2015 of the new rays. About six weeks after his discovSince the early 2000s, there was a more rapid decline in Work was done on gray paper treated with coffee and ery, he took a picture—a radiograph—using x-rays surgical interventions. This change has been achieved povidone-iodine for warmth and texture. Black pan pastel. Charcoal pencils and white chalk. 20 x 25. of his wife Anna Bertha’s hand. When she saw her due to improvements in laboratory testing, CT scans skeleton, she exclaimed, “I have seen my death!” (a more sophisticated successor to the x-ray, invented Artist: Moises Menendez, MD, FACS The new rays came to bear his name in many 75 years later), and MRI—techniques that have made languages as “Röntgen Rays” (and the associated x-ray x-ray flourished, with little regard for potential side exploratory laparotomy less common for diagnostic purradiograms as “Röntgenograms”). Clinical use of the effects from radiation exposure. But x-rays have other poses outside of the severe trauma setting.

By MOISES MENENDEZ, MD, FACS

IN THE NEWS

APRIL 2022 / GENERAL SURGERY NEWS

to eight weeks after infection, patients still experienced increased rates of postoperative pneumonia. Surgery eight weeks after a COVID-19 diagnosis was not associated with increased complications. All patients in the study were diagnosed with COVID-19 between March 1, 2020, and May 30, 2021. These studies predate the omicron variant. According to the CDC, this variant causes less severe disease and is more likely to reside in the oropharynx and nasopharynx without infiltration and damage to the lungs. However, it’s unclear whether this will lead to fewer postoperative complications, given that SARS-CoV-2 affects organs beyond the pulmonary system, the ASA/APSF statement cautioned. The organizations also recommended that: • any delay in surgery needs to be weighed against the time-sensitive needs of the individual patient;

continued symptoms not exclusive of pulmonary symptoms; and • the decision to proceed with surgery should consider the severity of the initial infection, the potential risk for ongoing symptoms, comorbidities and frailty status, and the complexity of surgery. American surgical organizations have not issued broad recommendations on timing of elective surgery for patients with COVID-19. In January 2022, the American College of Surgeons issued a statement for the public that highlighted the essential

nature of elective surgery, but the organization did not comment on the timing of elective surgery. Surgeons and hospitals across North America are trying to manage backlogs of delayed operations while facing issues about how and when to go forward with elective procedures. At Montreal’s McGill University, where Liane Feldman, MD, is the Edward W. Archibald Professor and Chair of Surgery, surgeons recommend a delay of six weeks, if possible, after COVID-19 infection in immunocompetent patients, she said.

“But ultimately, I think it comes down to a discussion, like any risk assessment situation for surgery, between the surgeon, the surgical team and the patient,” she said. “There are things that can wait and things that can’t, and it’s a balance of the risks.” Dr. Feldman is the president of the Society of American Gastrointestinal and Endoscopic Surgeons. The ASA/APSF guidance is under continuous review, according to the organizations. Recommendations will be updated as additional evidence becomes available, they said. ■

Free CE/CME now available! 1.0 AMA PRA Category 1 Credit™ 1.0 AANP credit 1.0 ACPE credit 1.0 ANCC credit

• if surgery is deemed necessary during a period of likely increased risk, potential risks should be included in the informed consent and shared decision making with the patient; • additional delays in operating should be considered if the patient has

Today, Röntgen is considered the father of diagnostic radiology, the medical specialty that uses imaging to diagnose disease. While he accepted the honorary degree of doctor of medicine offered to him by his own university, he never took out any patents on x-rays, to ensure the world could freely benefit from his work. His altruism came at a considerable personal cost—at the time of his death in 1923, Röntgen was nearly bankrupt from the effects of inflation following World War I. ■

Sources History of Medicine: Dr. Röentgen’s accidental x-rays. https://columbiasurgery. org/news/2015/09/17/history-medicinedr-roentgen-s-accidental-x-rays

Safe Opioid Prescribing A Patient-Centered Approach to the FDA Blueprint A 3-Part Series RELEASE DATE: OCTOBER 27, 2021

EXPIRATION DATE: DECEMBER 31, 2022

This activity is jointly provided by Global Education Group and Applied Clinical Education.

CHAIR Charles E. Argoff, MD

FACULTY

https://chicagoradiology.org/?page_id=496

These activities are supported by an independent educational grant from the Opioid Analgesic REMS Program Companies.

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Reed AB. The history of radiation use in medicine. J Vascular Surg. 2011;53(1 suppl):3S-5S.

This activity is intended to be fully compliant with the Opioid Analgesic REMS education requirements issued by the U.S. Food and Drug Administration (FDA).

Yvonne M. D’Arcy, CRNP, CNS Marc R. Gerber, MD Courtney M. Kominek, PharmD, BCPS, CPE Bill H. McCarberg, MD, FABM

INDEPENDENT REVIEWER Michael Clark

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Schneider D. The Invention of Surgery: A History of Modern Medicine. Pegasus Books; 2020:311.

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THE SCIENCE BEHIND POSITIVE PATIENT OUTCOMES

Advanced Surgical Energy—Clinical Experience With the POWERSEAL™ Sealer/Divider Curved Jaw, Double-Action Justin Maykel, MD Joseph M. Streeter and Mary Streeter DeFeudis Chair in Surgery Chief, Division of Colon and Rectal Surgery University of Massachusetts Memorial Medical Center Worcester, Massachusetts

Introduction For surgeries performed within the abdominal cavity—particularly colorectal surgical procedures—advanced bipolar surgical energy devices have enabled clinicians to provide fast and effective hemostasis while avoiding the use of clips or sutures and preventing thermal spread caused by monopolar devices.1-3 As such, the sealing of blood vessels using bipolar energy devices has become a surgical standard alongside the advancement of laparoscopic surgery.1,2 Data comparing surgical energy technologies have shown that bipolar devices provide successful, safe sealing,4 with this technology typically offering the capability of sealing vessels up to 7 mm in size.5 By building on the technology of devices with established utility, surgical energy device manufacturers have sought to provide additional features not only to improve sealing ability, but also to enhance multifunctional capability, device ergonomics, and ease of use. A curved and tapered double-action jaw, a wider jaw aperture, and longer jaw length promote effective and more efficient grasping and dissecting of tissue as well as sealing of wider vessels.6 By using the jaw to atraumatically grasp tissue and provide reliably fast sealing, dissection speed often is accelerated and the need for additional instruments may be minimized.6,7 With less squeeze force to close the jaws, hand fatigue may be reduced.7 Thus, as newly developed instruments become available, new and intuitive features often combine strong sealing with improved grasping, more efficient tissue dissection, versatility, and improved ergonomics during the course of laparoscopic surgical procedures.

POWERSEAL™ Sealer/Divider Curved Jaw, Double-Action One of the most recent advancements in the bipolar surgical energy device field is the Olympus POWERSEAL™ 5-mm Sealer/Divider Curved Jaw, Double-Action. Introduced in fall 2021, POWERSEAL Sealer/Divider is the first device in a new family of advanced bipolar energy products from Olympus

GENERAL SURGERY NEWS • APRIL 2022

with the aim to combine the high-quality surgical performance clinicians have come to expect with a multifunctional design and improved ergonomics. The POWERSEAL Sealer/Divider is a bipolar electrosurgical device indicated to provide ligation and division of vessels, including pulmonary vessels, tissue bundles, and lymphatics, up to 7 mm for laparoscopic, minimally invasive, and/or open surgical procedures. POWERSEAL Sealer/Divider can be used in various surgery types including general surgery and colorectal, gynecologic, bariatric, urologic, thoracic, and vascular surgery.8 In addition to providing sealing of vessels up to and including 7 mm in less than 3 seconds, on average,9,10 the instrument design focuses on providing features to improve efficiency and ergonomics for the surgeon including minimizing handreach distances to landmarks, such as the energy activation button or shaft rotation wheel while reducing squeeze force for the jaw lever.8-13 “The POWERSEAL Sealer/Divider stands out as an option in regard to its functionality, its reliability, and the level of comfort in the way it sits in your hand,” said Justin A. Maykel, MD, the Joseph M. Streeter and Mary Streeter DeFeudis Chair in Surgery and Chief of the Division of Colon and Rectal Surgery at University of Massachusetts Memorial Medical Center, in Worcester, Massachusetts.

Real-World Experience Dr Maykel participated in preclinical studies with the POWERSEAL Sealer/Divider and now has

performed multiple laparoscopic colectomies since the device received regulatory approval. Dr Maykel has found that the vessel sealing capabilities are comparable and often better than other available bipolar sealing devices—average seal time less than 2.8 seconds on vessels up to 7 mm in diameter9,10—offering uniform tissue compression for strong sealing. Also, “the antistick surface of POWERSEAL Sealer/Divider and how that surface is maintained over serial firings is an advantage compared to many of the reprocessed products, where the divided tissues can stick to the instrument jaw,” Dr Maykel said. “POWERSEAL Sealer/ Divider does seal somewhat faster and, of course, this advantage is helpful when trying to work efficiently.” For colectomies, which have multiple steps as the colon is first mobilized and then separated from the mesentery, manipulation and dissection of the tissue along with devascularization can be time-consuming and delicate, he noted. “If you can introduce one instrument with multiple functions, you can eliminate time wasted in instrument exchange,” Dr Maykel said, referring to potentially cumbersome steps required to move tools in and out of the laparoscopic port. “I prefer how the POWERSEAL Sealer/Divider is effective for grasping and lifting the tissue, while dissecting it and sealing the blood vessels without any instrument transfers.” Whenever possible, the opportunity to dissect and seal tissue in complex anatomy with a single device can accelerate operating time.6,7 “A total colectomy can take 3 hours. The fact that you can use this one instrument for much of the actual resection speaks to

Figure. Comparison of reach to device landmarks (left),a and jaw aperture, jaw length, and cut length (right)b between the POWERSEAL™ 5-mm Sealer/Divider Curved Jaw, Double-Action and LigaSure™ Maryland Jaw advanced bipolar energy device. a

Internal test report DN0046457.

Based on internal Olympus test methods.

Reprinted from reference 15.

Supported by

In experienced hands, advanced bipolar energy devices are relatively safe, but Dr Maykel was pleased with the design element of placing the lever for opening and closing the dissecting blades on the opposite side of the device from the button used to activate energy. This placement, he said, helps reduce the risk for confusion and firing in the wrong sequence. “The POWERSEAL Sealer/Divider also is a smart device in that it reads tissue conditions and signals when the vessels have been sealed and no further energy is needed,” he said. “With a beep, the device tells you when it has run its cycle and stops firing.” Other devices have similar features, but Dr Maykel said the smart signaling might have an additional advantage with the POWERSEAL Sealer/Divider because the device can seal vessels more rapidly. Although faster, the POWERSEAL Sealer/Divider is

Comparison With Other Devices Preclinical studies have generated metrics that demonstrate differences between the POWERSEAL Sealer/ Divider and other commonly used advanced bipolar energy devices. When compared with the LigaSure™ Maryland Jaw advanced bipolar energy device, for example, the jaw length of the POWERSEAL Sealer/ Divider is 7% longer (22.5 vs 21.0 mm), the jaw aperture is 15% wider (19.1 vs. 16.6 mm), and the cut length is 6% longer (19.3 vs 18.2 mm) (Figure).15,16 In addition, the jaws do not need to be closed to activate the energy.15 Furthermore, there are ergonomic differences: The reach from the palm of the hand holding the device to squeezing the jaw lever is shorter (50.7 vs 53.5 mm).11,15 The device also is designed to require less squeeze force to close the jaws. When compared with the LigaSure device, the squeeze force of the POWERSEAL is reduced by 55% while continuing to provide strong jaw force and sealing strength.12,16 For activating the cutting blade, the reduction is 10% without sacrificing cutting effectiveness.11,15 “I have found the device safe, but also easy to use even for longer procedures without any discomfort or hand fatigue,” Dr Maykel said. “I can say that I have experienced fatigue with other devices.” When tissue is grasped, there is a latch-on setting to maintain the jaw position while sealing vessels.11 This feature was designed for situations in which securing the jaw position while manipulating adjacent tissue is advantageous. Again, the POWERSEAL Sealer/Divider was designed for versatility in a broad range of abdominal laparoscopic resections. “I was trained as a general surgeon, but my practice has become largely devoted to colorectal procedures. I cannot speak to how this device would perform in urologic, bariatric, or other forms of surgery, but it seems to me that its features would have utility in other procedures that employ advanced bipolar energy to dissect and seal vessels,” he said. The POWERSEAL Sealer/Divider has not been shown to be effective for tubal sterilization or tubal coagulation for sterilization procedures. During surgical procedures in which patients exhibit certain types of vascular pathology (eg, atherosclerosis, aneurysmal vessels), apply the seal to unaffected vasculature for best results. As POWERSEAL Sealer/Divider utilizes advanced bipolar energy, consult first with a qualified professional (eg, cardiologist) prior to using on patients who have electronic implants, such as cardiac pacemakers, to avoid possible hazard due to interference with electronic implant.

Dr Maykel keeps metrics on his cases but noted that comparing advanced bipolar energy devices on the basis of hard outcomes, such as intraoperative or postoperative bleeding rates, would be difficult. These types of complications among experienced surgeons are rare. “I have done thousands of colectomies, so I know advanced bipolar energy devices are safe and effective,” he said. However, he indicated that this does not mean all bipolar surgical energy devices are interchangeable. As device design has improved, they are easier and more efficient to use in routine as well as more challenging resections. In addition, “I think one of the most important aspects of this device is not just that it works, but it works reliably,” Dr Maykel said.

Conclusion The POWERSEAL Sealer/Divider has introduced a variety of refinements to create a tool that delivers the high-quality sealing surgeons expect alongside greater versatility, efficiency, and surgeon comfort than competing devices with similar applications to provide an enhanced surgical energy experience.8 According to Dr Maykel who has completed a series of colectomies using the POWERSEAL Sealer/Divider, the device is faster at sealing vessels, versatile in the many steps needed to mobilize and free the colon, and reliable. The relative advantages include a jaw design that facilitates manipulation of the energy device into position, smart technology that confirms vessel sealing, and intuitive operational features that make it easy and safe to use.11

References 1. Janssen PF, et al. Surg Endosc. 2012;26(10):2892-2901. 2. Hotta T, et al. World J Gastrointest Surg. 2012;4(1):1-8. 3. Okhunov Z, et al. J Endourol. 2018;32(4):329-337. 4. Person B, et al. Surg Endosc. 2008;22(2):534-538. 5. Chekan EG, et al. Med Devices (Auckl). 2015;8:193-199. 6. Seehofer D, et al. Surg Endosc. 2012;26(9):2541-2549. 7. Lin HZ, et al. ISRN Min Invas Surg. 2013:1-4. Article 453581. 8. Olympus America Inc. Accessed March 1, 2022. https:// www.olympus-global.com/news/2021/contents/nr02198/ nr02198_00001.pdf 9. Data on file. Internal test report DN0043135. Olympus America Inc. 10. Data on file. Internal test report DN0044249. Olympus America Inc. 11. Data on file. Internal Design Verification electrical & mechanical test report DN0046457. Olympus America Inc. 12. Data on file. GLP Acute & Chronic animal studies reports DN0044705, DN0044706. Olympus America Inc. 13. Data on file. Internal vessel sealing report DN0044404. Olympus America Inc. 14. Sankaranarayanan G, et al. Surg Endosc. 2013;27(9): 3056-3072. 15. Data on file. Product information kit. Olympus America Inc. 16. Data on file. Internal test report DN0044405. Olympus America Inc. Disclosure: Dr Maykel is a paid consultant to Olympus Corporation of the Americas, SafeHeal, and Takeda.

LCR43642V01

POWERSEAL™ Sealer/Divider Functionality

as effective as other leading devices, according to Dr Maykel. In his experience using the device so far, he and his team have not experienced any significant bleeding events. Dr Maykel credits the absence of intraoperative and postoperative complications to the reliable dissection and sealing functions of the device.

BB221

its versatility. The POWERSEAL Sealer/Divider speeds up the procedure and keeps the work flowing,” he said. Advanced bipolar energy devices like the POWERSEAL Sealer/Divider, which employs radiofrequency energy, grasp tissue in their jaws for dissection and sealing.8 When the jaws are clamped on target tissue, jaw pressure along with energy delivery contribute to vessel sealing.14 In advancements with the POWERSEAL Sealer/Divider, the jaw aperture is 15% wider than the LigaSure™ Maryland Jaw (Medtronic), a latch-on/latch-off setting accommodates surgical preference, and energy can be activated without the jaws being fully closed when needed by the surgeon, among other features.11 “Rather than one fixed jaw, both jaws open, which can really help when encountering thicker tissue. It makes it far easier to grasp,” Dr Maykel said. Longer jaws permit a greater maximum quantity of tissue to be grasped, which can be a relative advantage in specific instances, according to Dr Maykel. Moreover, he described the device as easy to manipulate in tight spaces. “The jaws cannot be angled, but they can be rotated 330 degrees, which permits greater articulation and maneuverability than many other devices,” he said, crediting this design for particular efficiency when manipulating into position through tight spaces. For surgeons with experience using an advanced bipolar energy device, the POWERSEAL Sealer/Divider should provide a familiar experience, according to Dr Maykel. “The POWERSEAL Sealer/Divider is a plugand-play type product. It is highly intuitive,” he said. With the POWERSEAL Sealer/Divider, the principles of bipolar energy delivery and the skills for dissection and vessel sealing are also easily accessible, according to Dr Maykel. “I have worked with residents on every case I have performed so far with the POWERSEAL Sealer/Divider, and they have uniformly found the device easy to use,” he added.

For more information about the POWERSEALTM Sealer/Divider, please visit: https://medical.olympusamerica.com/products/powerseal. GENERAL SURGERY NEWS • APRIL 2022

GENERAL SURGERY NEWS / APRIL 2022

Beyond Your First Contract: Networking Is Key for Job Seekers continued from page 1

a partner on leave and, in recent times, the threat of COVID-19 can result in even the most basic needs of security and safety not being met, said Jennifer Tseng, MD, an assistant professor of surgery at the University of Chicago Pritzker School of Medicine. “When we are overloaded with work and feel a lack of control, our basic needs are compromised. If there is a breakdown of community, or insufficient external rewards, our psychological needs are not being met,” Dr. Tseng said. She recommended taking stock of your satisfaction level on a regular basis, and keeping your curriculum vitae up to date. “Your needs may be different than when you first finished training or initially joined your first practice,” she said. Establishing immediate, five- and 10-year goals can help with self-assessment and evaluation of your professional life. “If the model you chose initially is not working out for you, admit this and don’t be afraid to seek another practice environment,” Dr. Tseng said.

3 Types of Job Seekers Dr. Chen stratified job seekers into three tiers: those actively seeking a new position (contract is ending, need to relocate); those actively listening (seeking change, but under no time pressure); and those who are passively open (satisfied with current job, but receptive to new opportunities). Active seekers should take a multipronged approach,

fully activating their network, he said. “No one should be in the dark, including your current boss. Answer recruiter emails and calls, consult job boards and contact employers who might match your profile. There’s no harm in calling or emailing people, saying, ‘I’m moving to your city and would love to work for you.’” For most active seekers, referrals and networking are what lead to a new position, Dr. Chen said. “For your second job, networking tends to be even more important.” Active listeners might be engaged in more goaldirected networking, “letting people know you’re interested in a particular position, say a division chief or chair, and to tell you if they hear of anything,” he said. Mentorship relationships can be particularly helpful in this situation, “to help you identify what things you care about for your next job.” For those who are just keeping an ear to the ground, casually taking calls from recruiters and friends, it’s important to know what would clearly spur you to leave your present situation. “Is it a title? Having more research money? Location? You have to understand what would convert you from being passively open to actively pursuing a position. Be willing to listen, but quickly discard whatever fails to meet your profile,” Dr. Chen said. Also, bear in mind that sometimes the best way to improve your situation is not necessarily to find a new one. “Sometimes it’s just improving your current job,” he said.

It’s All About the Network The three scenarios that Dr. Chen described are very different, but all of them include networking as a key component of finding a new and satisfying position. For some people, the notion of networking calls to mind a transactional exchange—one of which few want to be on either end. But Dr. Chen suggested thinking of networking in a different way. “The basis of networking is the process of interacting with someone else to exchange information and develop social or professional contacts. At its very basis is a give-and-take of the personality that leads to a friendship,” Dr. Chen said. He recommended finding common ground to build on, such as being from the same city or following the same sports teams. “Good networks have benefits that flow in all directions, so part of it is offering help wherever you can, but avoid requests that require significant political capital until you’ve really developed that relationship and it feels natural to you.” Dr. Chen acknowledged that networking with a roomful of strangers—presumably people with whom you have not laid the foundation for a balanced relationship—can be intimidating. So, he offered several suggestions for making the most of it: “Be yourself. Don’t cling to the one person you know. Ask other people questions and be present in the conversation. Spend 10 minutes with four or five people rather than 45 seconds with a dozen. Have business cards and a fully charged cell phone and an updated CV ready to share. If someone says to follow up, please do.” ■

Expert Panel Advises on Preventing SSIs After Colorectal Surgery continued from page 1

The goal is to reduce the evidence that off-midline incisions rounds of discussion for each topic. Voting evid burden of SSIs, said senior or reduce the risk for SSIs compared was anonymous, as is “standard” in this type red author Traci Hedrick, MD, D, with midline incisions, but when of process, Dr. Hedrick said, so voters aren’t w FACS, FACRS, a colorectall possible and appropriate, off-mid- influenced by their peers. Every recomsurgeon at the University off line incisions may reduce incision- mendation had to reach at least 70% agreeVirginia Health System, al hernia risk after (laparoscopic) ment among voters. “We reviewed each of in Charlottesville. colorectal surgery. With the size the topics with a fine-toothed comb and “Most of these recof bite sutures, the authors said did a thorough review of all the evidence,” ommendations are on Traci Hendrick, MD, there was not enough evidence she said. “We took our time resolving each topics that surgeons are FACS, FACRS to conclude that a small bites of the recommendations.” already familiar with,” suture technique does more to The report offers practical advice to Dr. Hedrick said. “However, the intra- reduce SSI risk than a large bites suture help surgeons prevent one of the most operative aspects can sometimes get technique. However, they said the small common, and costly, complications follost in the large comprehensive bundles, bites suture technique can reduce the risk lowing colorectal procedures, said Syed which is why this project is unique.” for incisional hernias. Regarding wound Husain, MD, FACS, FASCRS, a colorecTo prevent SSIs, the authors sug- irrigation, use aqueous iodine, not antibi- tal and general surgeon at The Ohio gest surgeons employ wound protec- otic incisional wound irrigation, in high- State University, in Columbus, who did tors/retractors, negative pressure wound risk, contaminated wounds. not participate in the study. “These are therapy, triclosan-coated sutures, a sterTo reach a consensus, the panel followed the questions that we grapple with on ile incision closure tray and change their a modified Delphi method, with up to three a daily basis, and the authors have gone gloves before closing the incision. AlterWound Negative Continuous vs. natively, they found that there was insufOff-midline Topical skin Subcutaneous protectors/ pressure interrupted ficient evidence to recommend topical incisions adhesives drains retractors wound therapy sutures skin adhesives, incise/adhesive drapes, Small bites vs. Incise/ Delayed advanced dressings, continuous versus TriclosanSterile incision large suture adhesive incision interrupted sutures or staples, a delayed coated sutures closure tray bites drapes closure incision closure, and subcutaneous drains to specifically prevent SSIs (Figure). Pre-closure Wound Advanced Sutures vs. With some topics, the advice was glove change irrigation dressings staples more complex—not a simple do or don’t do, Dr. Hedrick said. For instance, Positive Recommendation Mixed Negative Recommendation when it comes to midline incisions, the Figure. Consensus on intraoperative techinical/surgical aspects of SSI prevention. panel determined there was insufficient Adapted from J Am Coll Surg 2002;234(1):1-11.

really to the heart of the problem.” The result of these discussions by the expert panel in the report is extremely helpful to practicing surgeons, Dr. Husain said. For instance, his practice frequently uses glue sealants on top of incisions. Although he and his colleagues haven’t stopped yet, these recommendations have “definitely started a conversation in our group.” If they don’t stop entirely, they may begin to employ glue sealants more selectively, he added. “There’s a very good chance that we’re going to move away from the blanket application in all patients.” His practice also doesn’t usually have access to antibiotic-impregnanted sutures. But after the panel recommended their use to prevent SSIs, “that has again started a conversation in our group and administration to have those available to us.” It can be hard to determine how best to prevent SSIs, Dr. Husain said, because doctors can’t easily try something to see what works. In the future, the surgical community will hopefully find a way to conduct randomized, prospective trials of techniques to reduce SSI risk in a way that won’t compromise patient care, he added. ■ Disclosures: Dr. Hedrick is a consultant to Ethicon/Johnson and Johnson, which provided funding for the study. Dr. Husain reported no relevant financial disclosures.

IN THE NEWS

APRIL 2022 / GENERAL SURGERY NEWS

Rebranding Hernia Surgery to Reflect Full Breadth of the Field By KATE O’ROURKE

n recent years, most members of the board of governors at the American Hernia Society have aimed to rebrand the field of hernia care as abdominal core health, the discipline as abdominal core surgery and the identity of associated clinicians as abdominal core surgeons (JAMA Surg 2020:155[3]:185-186). At the annual meeting of the American Hernia Society, Benjamin Poulose, MD, MPH, the co-director for Abdominal Core Health at The Ohio State University, in Columbus, updated the progress of this endeavor. “We are the only specialty in general surgery that defines ourselves by a disease. If you look at other subspecialties, they are defined as vascular surgeons or colorectal surgeons for example,” said Dr. Poulose, who is also the Robert M. Zollinger Lecrone-Baxter Chair and Chief of General and Gastrointestinal Surgery at The Ohio State Wexner Medical Center. “In recent years, the Americas Hernia Society and the Abdominal Core Health Quality Collaborative (formerly the Americas Hernia Society Quality Collaborative) have had an increased focus on this concept of core health. It is really being adopted in many ways that we expected and in many unexpected ways.” The whole idea behind the rebranding effort to abdominal core health is that defining the field by hernia alone is limiting. Dr. Poulose pointed out that the abdominal wall, lower back, diaphragm, and pelvic floor are all components that contribute to abdominal core function, which influences activities of daily living and can be measured in self-reported quality of life. “Hernia, although a significant component of what we take care of in terms of disease processes, doesn’t really define the breadth of what we do as far as abdominal wall or abdominal core surgeons,” Dr. Poulose said. “These are parts of the body that are interrelated and work together to allow patients to do things on a day-today basis. Our move toward subspecialization moves those components away from each other, which makes it difficult to keep the bigger picture in mind.” Dr. Poulose said Centers for Abdominal Core Health help take care of patients with not just hernias, but patients with tumors of the abdominal wall or patients with diastasis after pregnancies, for example. “Centers for Abdominal Core Health integrates other components of therapy not just surgery, such as integrative medicine, and alternative medical therapies such as therapeutic yoga and acupuncture. Physical therapy and movement are also part of this paradigm

ostoperashift both in terms of postoperaenance tive recovery and maintenance ulose of core health,” Dr. Poulose said. Research is just starting ng to recognize and explore re the underappreciated bennefits of stabilizing the he anterior abdominal wall. ll. Investigators are aiming to find out whether repairing someone’s

debilitat debilitating anterior abdominal wa wall hernia can improve how tthey breathe, improve their bowel function, imp improve their pelvic floor fun function, or reduce their chr chronic back pain. Simila ilar to the way bariatric su surgeons learned that re reducing weight can ccure diabetes, cure high bblood pressure, reduce

cancer risk, and improve longevity, hernia surgeons are realizing that their interventions can impact various other aspects of health, not just the hernia itself. “We are now getting initial data from colleagues in Sweden that show you can improve pelvic floor function after repairing someone’s postpartum diastasis. We also have evidence that you can improve pulmonary function by fixing a ventral hernia. Our colleagues in Italy continued on page 19

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GENERAL SURGERY NEWS / APRIL 2022

Surgery and COVID-19, Sigmoid Cancer, Gallstone Pancreatitis, Inguinal Hernia Repair n this installment of Journal Watch, we welcome guest columnist Ian Kratzke, MD, who is a general surgery resident and current research fellow at the University of North Carolina at Chapel Hill. He takes a closer look at recent articles evaluating optimal timing of surgery after COVID-19 infection, extent of mesenteric resection for sigmoid cancer, and two cost analyses evaluating cholecystectomy for gallstone pancreatitis and the other on techniques for inguinal hernia repair. We hope readers will find these reviews worthwhile and relevant to the scope of a general surgeon’s practice.

Reducing Postoperative Complications After COVID-19 Infection

risk for postoperative pneumonia compared with the pre‒COVID-19 patient cohort, which served as a control group. Early post‒COVID-19 patients also had an increased risk (98%) for postoperative pneumonia comIn the Annals of Surgery, Deng et al published an anal- pared with the control group. Interestingly, the authors ysis of postoperative complication rates in patients who found patients in the late post‒COVID-19 group did recovered from SARS-CoV-2 infection and required not have an increased risk for any of the postoperative major elective surgery (Ann Surg 2022;275[2]:242- complications. 246). This was a retrospective analysis of the COVIDAfter adjusting for patient characteristics and type of 19 Research Database using the Symphony Health data surgery, patients with a SARS-CoV-2 diagnosis withset, which includes claims from more than 1,500 hospi- in four weeks of surgery had significantly higher risks for developing pneumonia (adjusted odds ratio [aOR], 6.46), respiraPostoperative complication rates in patients who recovered from tory failure (aOR, 3.37), pulmonary SARS-CoV-2 infection and required major elective surgery embolism (aOR, 2.73) and sepOUTCOME OUTCOME STUDY POPULATION sis (aOR, 3.67). Even patients with SARS-CoV-2 diagnosed four to eight weeks prior to surgery had an increased risk for postoperative pneu>8 monia (aOR, 2.44), yet those diagnosed more than eight weeks before Patients undergoing major 480% increased risk of No increased risk of post-op elective surgeries, stratified by post-op pulmonary complications for patients with surgery did not. timing of COVID-19 infection complications for patients with distant infections (>8 weeks) The authors should be lauded for (including no diagnosis) recent infections (<4 weeks) their work in adding to the developDeng et al. Ann Surg. 2022 ing literature on the operative risks associated with COVID-19. This tals and health plans, totaling 280 million patients at the study is unique in that it focuses on the U.S. populatime of the study. Data were collected using International tion undergoing major elective surgeries and evaluates Classification of Diseases for Oncology (ICD-10-CM) risk based on the timing of the SARS-CoV-2 diagnoand Current Procedural Terminology (CPT) codes. sis. While the decision for when to perform an elective Patients were included if they had a COVID-19 surgery after a COVID-19 infection requires considerdiagnosis between March 1, 2020, and May 30, 2021. ation of many factors (e.g., oncologic risks), based on They were stratified by the timing between diagno- this study’s findings, major elective operations should sis and surgery into four groups: peri‒COVID-19 (0 be postponed for at least eight weeks after a SARSto four weeks after infection), early post‒COVID-19 CoV-2 diagnosis to reduce postoperative complication (four to eight weeks), late post‒COVID-19 (more than rates, which may be increased in patients with recent eight weeks), and pre‒COVID-19 (no diagnosis before COVID-19 infection. or 30 days after surgery). A wide range of major elective surgeries were included, such as cardiac, gastrointestinal, Survival and Patient-Reported gynecologic, hepatobiliary, neurosurgical, orthopedic, Outcomes in Complete thoracic, urologic and vascular. Patients were excluded if they underwent multiple operations, or if the operation Mesocolon Excision was considered urgent or minor. Complications includ- In the Annals of Surgery, Planellas et al published results ed pneumonia, respiratory failure, thrombosis, arrhyth- from a clinical trial comparing standard and extended complete mesenteric excision (CME) in adult patients mia and sepsis. Of 5,479 patients who met the study criteria, 14.2% with sigmoid cancer (Ann Surg 2022;275[2]:271-280). were in the perioperative group, 8.1% were early post- Standard CME included harvesting lymphofatty tissue infection, 29.8% were late post-infection, and 47.8% along the inferior mesenteric artery (IMA), whereas were pre‒COVID-19. Most patients had mild infec- extended CME included the additional harvest of tistion, with less than 2% having severe or critical disease. sue surrounding the inferior mesenteric vein (IMV) to Hysterectomy was the most common procedure among the end of the left colic artery. Four high-volume cenall patients. Peri‒COVID-19 patients experienced the ters participated, and all operations were initially perhighest rate of complications, with a 480% increased formed laparoscopically or robotically.

Arielle Perez, MD, MPH, MS Director of UNC Health Hernia Center and Assistant Professor of Surgery in the Division of General, Acute Care, and Trauma Surgery at the University of North Carolina at Chapel Hill School of Medicine —Column Editor

Ian Kratzke, MD General Surgery Resident and Research Fellow University of North Carolina at Chapel Hill —Guest Columnist

Enrolled patients had either confirmed sigmoid colon adenocarcinoma or unresectable dysplastic adenomas. Patients with unresectable metastasis, synchronous tumors or need for terminal colostomy were excluded. Outcomes included the number of lymph nodes harvested, disease recurrence and two-year survival rate. The authors also collected patient-reported outcomes of intestinal and genitourinary function, which were measured using standardized questionnaires administered preoperatively and one year postoperatively. A total of 93 patients were included for analysis, with 47 in the standard group. There were no significant differences in patient demographics between groups, nor in conversion to open rates or operative times. Additionally, complication rates, hospital length of stay and tumor stage were similar in both groups. The standard CME group had a median of 20 lymph nodes harvested, whereas the extended CME group had 21 (P=0.873), for a median of one additional lymph node harvested in the extended group, none of which were positive for disease. Five patients in each group developed metastatic disease, with no significant difference in the two-year overall survival rate between groups (standard surgery, 97.6%; extended surgery, 95.1%; P=0.559). There were also no differences in bowel dysfunction scores between groups, nor in female patients’ genitourinary dysfunction scores. In contrast, male patients in the extended CME group reported worse urinary dysfunction 12 months after surgery (P=0.026), and male patients in the standard CME group had worse recovery of sexual function (P=0.046). This study adds to the ongoing investigation into what extent of lymph node dissection in colon cancer will most benefit the patient. Remarkably, the authors did not find differences in the number of lymph nodes harvested with more extensive dissections, which is congruent with findings that extended dissections did not provide greater disease-specific benefit to the patients. This contrasts with previous data demonstrating greater nodal yield with larger dissections. This study’s focus on only sigmoid cancer may explain this discrepancy and is an important strength of this trial. Another strength is the inclusion of postoperative bowel and genitourinary function measures, which highlight the potential consequences of more aggressive lymph node harvests. Given the limited number of patients included in this study and the focus on minimally invasive techniques performed at high-volume centers, the generalizability of these results may depend on surgeon experience, preoperative workup and patient-specific factors. For surgeons providing a minimally invasive sigmoid colectomy resection, avoiding unnecessary extended mesocolon resections should be considered.

JOURNAL WATCH

APRIL 2022 / GENERAL SURGERY NEWS

costs, material costs for laparoscopic repair were higher (1.5 times; P<0.001) than open repair, but overhead costs were lower (0.81 times; P=0.003) than for an open In the Journal of the American College of Surgeons, repair, due to the shorter mean calculated operating Isbell et al published results from a secondary analytime of laparoscopic repair compared with open (82 vs. sis of the Gallstone PANC Trial (Gallstone Pancreati107 minutes). All domains of variable costs for robotic tis: Admission vs Normal Cholecystectomy) (J Am Coll repair were higher than for the other approaches. Surg 2021;233[4]:517-525.e1). That trial was a sin- Open Versus Laparoscopic Taking all costs and considering the revenues assogle-center, randomized controlled trial evaluating the ciated with each approach, the authors found the lapVersus Robotic Inguinal Hernia 30-day hospital length of stay (LOS) among patients aroscopic inguinal hernia repair had a gross margin with mild gallstone pancreatitis who receive early (≤24 Repair 4% higher than the open approach, while the robotic hours of admission) cholecystectomy versus cholecys- In the Annals of Surgery, Glasgow et al published a cost repair’s margin was only 4% of the open repair margin. tectomy after clinical resolution of pancreatitis. analysis that compared the value of three approaches to This led to a final calculation of the value of each miniThis trial found early cholecystectomy was associated inguinal hernia repair (Ann Surg 2021;274[4]:572-580). mally invasive repair compared with the open approach with a shorter LOS but an increase in non‒life-threat- This was a single-center, retrospective study of patients as follows: Laparoscopic repairs reduce value by 3%, ening complications. It should be noted, however, that undergoing unilateral inguinal hernia repair with an whereas robotic repairs reduce value by 69%. patients with a high likelihood of choledocholithiasis open, a laparoscopic or a robotic technique. Current The authors conducted a well-done cost analysis of a (bilirubin >1.8 mg/dL; bile duct >6 mm) were excluded Procedural Terminology (CPT) codes were used to highly debated topic regarding value, and their findings from the study because they were more likely to receive identify procedures performed by 14 surgeons, all of echo those of cost analyses by Charles et al (Surg Endosc preoperative endoscopic retrograde cholangiopancrea- whom were experienced in the surgical approach used. 2018;32[4]:2131-2136) and Abdelmoaty et al (Surg tography (ERCP). Value was defined as quality divided by cost, in Endosc 2019;33[10]:3436-3443). Based on this study, This retrospective cost analysis used patient more expensive technology for unilateral inguidata from the Gallstone PANC Trial and nal hernia repair is associated with increased Comparing Open vs. Laparoscopic vs. Robotic Inguinal Hernia Repair collected additional data from the hospital cost. However, limitations in this cost analysis accounting system related to follow-up clininclude selection bias and the assumption that Laparoscopic repairs have Laparoscopic repair Robotic repairs even more shorter mean time, yet costlier than Open costly than laparoscopic ic or emergency department visits, as well as quality is equal among all three repairs for all higher overall costs 90-day readmission and discharge data. Costs inguinal hernias. Due to the consecutive nature were adjusted to 2020 U.S. dollars, and analyof procedure selection, rather than a randomses were considered from a healthcare system ized controlled trial, the reason for selecting perspective using frequentist and Bayesian each method is unclear and may introduce bias multivariate regression models. in the findings. Although the authors assume Robot Open Laparoscopic There were 49 patients in the early cholecysthe quality of repair is equivalent for all three 124 107 82 REDUCE VALUE 3% REDUCE VALUE 69% tectomy group and 48 patients in the control techniques, minimally invasive approaches in (minutes) arm. The authors found that within the 90-day certain patient populations (morbidly obese, Glasgow et al. Ann Surg. 2021 period, patients treated with early cholecystecwomen, bilateral hernia and recurrent hernia tomy had a significantly lower rate of preoperafter prior open repair), have been recommendative ERCP (0 vs. 6; P=0.01) and had a mean difference which quality (based on recurrence rate) was assumed ed due to their reduced recurrence and complication rate. of 0.96 fewer days of hospitalization (95% CI, ‒1.91 to to be equivalent for each repair, and cost was calculat- Additionally, surgical team factors, such as the participa0.00; P=0.05). These results were calculated to be an aver- ed as both fixed (basic OR equipment [e.g., surgical tion of a trainee and staff experience, can affect the operage reduction in cost by 8% and translated to $1,216 in instruments, laparoscopic systems and robotic systems ative case time, and thus the variable costs. savings per patient. The probability that patients receiv- use and maintenance]) and variable (“materials,” which As of 2015, 46% of surgeons provide only an open ing early cholecystectomy would incur reduced costs was included supplies used perioperatively; “providers,” approach to inguinal hernia repair. Preperitoneal dissecfound to be 81%. Four patients across the groups were which included surgeon and anesthesiologist time; and tion should be part of a surgeon’s armamentarium for “overhead,” which included cost per minute of OR time inguinal hernia repair and provides value to the patient found to have complications, all non-life-threatening. This study adds to the findings of the Gallstone and factors in support staff labor). Cost data were com- and the hospital system. It is unclear whether robotic PANC Trial by evaluating the hospital LOS up to 90 pared among approaches using linear modeling nor- surgery allows for an increased adoption of the preperidays post-discharge and including an evaluation of total malized to the open approach. The study involved 100 toneal repair, but based on current evidence from Kudsi costs within this same period stratified by the timing of consecutive patients undergoing each type of operation. et al (Hernia 2021;25[3]:755-764), the learning curve for The authors found that for fixed costs, the lapa- robotic repair is much shorter than for the laparoscopic cholecystectomy. Although the difference in LOS was found to be only approximately one day, given the inci- roscopic inguinal hernia repair was 1.03 times more approach. Surgeon experience, patient selection, surgical dence of patients presenting with mild gallstone pancre- expensive than an open repair, and the robotic repair team factors and operating equipment preferences affect atitis, this reduction in time and resources could translate was 3.18 times more costly than open. For variable procedure costs, especially given the relatively small to millions of dollars annually in the United States, as costs, laparoscopic repair was not significantly higher cost-related differences between open and laparoscopic well as a faster return to normal activity for patients. than the open approach (1.02 times; P=0.78), but robot- approaches. Nevertheless, as robotic surgery continues to However, the small sample size from a single center of ic repair was 2.11 times higher than open (P<0.001) expand in use, surgeons should recognize the potential ■ a specific subset of patients limits the generalizability and 2.06 times higher than laparoscopic. Within these increased costs associated with the technology. of this study. As such, additional data may be needed to capture the incidence of complications with early cholecystectomy compared with the benefit of reducing hospital LOS. Regardless, this study speaks to the need for surgeons to consider the severity of pancreatitis when determining the timing of cholecystectomy.

Cost of Early Cholecystectomy In Mild Gallstone Pancreatitis

➞

Female Patients continued from page 9

Surgeons have a responsibility to continually improve safety and quality, and that includes examining all the variables that affect outcomes on a population level, even surgeon gender, said Deborah S. Keller, MS, MD, a clinical assistant professor in the Division of Colorectal Surgery at the University of California, Davis Medical Center, in Sacramento.

➞

“The real task now is to drill down and find the cause of the association seen. Is it poor communication? Implicit bias? Is it the same cause in different hospitals and geographic areas?” Dr. Keller said. “Importantly, what outcomes in this equation matter to the patient? From these results, we can start to address the problem and create real change.” The operations in the study included coronary artery bypass graft,

femoral-popliteal bypass, abdominal aortic aneurysm repair, appendectomy, cholecystectomy, gastric bypass, colon resection, liver resection, spinal surgery (decompression and arthrodesis), craniotomy, knee replacement, hip replacement, open repair of the femoral neck, total thyroidectomy, neck dissection, lung resection, radical cystectomy and carpal tunnel release. These surgeries were performed across a variety of subspecialties to ensure

generalizability of the findings, including open and laparoscopic approaches, the authors said. “This is a macro-level study,” Dr. Jerath noted. “This study cannot make any inference about your practice. For patients, it does not reflect your surgeon’s practice. [But] we want surgeons and doctors to come into the profession who look like their patients, maybe have similar backgrounds and values and understanding of cultural tones.” ■

OPINION

Occult Inguinal Hernias: To Fix or Not to Fix? continued from page 1

2021; “The History of Robotic-Assisted Surgery,” September 2021], and examining how today’s approaches to inguinal hernias repair came about. During my research for these articles, I discovered that surgeons’ attitudes on how to handle incidental or occult inguinal hernias found at laparoscopy seems to have become even more divided and firmly held than I remembered from the early days of minimally invasive repairs. So, I performed a survey addressing this

question on the International Hernia Collaboration, a Facebook group for hernia surgeons, and the response became almost confrontational. Seventy-eight percent of the surgeons (373/477) responded that if an occult hernia was found on the opposite side during a laparoscopic inguinal hernia repair, it should be repaired immediately. A minority ardently disagreed. Therefore, I thought I would summarize the data supporting each side and then weigh in with my own opinion. It will

be up to you, the reader, to decide which approach is right for you and your patients (and contact us with your opinion). Looking back at the history of minimally invasive inguinal hernia repair, I realize there has been a fervent debate on how to handle the incidental hernia found during the laparoscopic procedure. Some have argued to always fix it; some have said to never fix it; and others have been on the fence, depending on the patient and the characteristics of

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the hernia. But before we have a battle with weighted gloves or bare knuckles, we must make sure we are talking about the same scenario. We must define what we mean by “occult” or “incidental” hernia. For this discussion, I will use a very narrow definition. I will define an occult hernia as one that is found on the opposite side during the minimally invasive repair of an inguinal hernia. The patient must not be aware that it is present when they undergo the repair. In other words, there are no preoperative signs, symptoms or radiological clues that it is present to the patient or surgeon. Proponents of fixing occult hernias that are discovered intraoperatively base their arguments on the incidence of occult hernias requiring repair in the future and what happens to patients who are part of watchful-waiting studies.1,2 More than two-thirds of patients with clinically detectable inguinal hernias who are in the watchful-waiting arm eventually undergo repair for the hernia. Surgeons argue they are saving the patient with an occult hernia from the unnecessary morbidity and cost of a second operation, and this justifies immediate repair. Let’s review the literature and see if we can, in fact, predict who these patients are and how often they would require repair of their occult hernia in the future. Then we can balance the chance of avoiding a second operation against the risk for causing harm by fixing the occult hernia in a patient who has no symptoms.

Do We Do More Harm Than Good? The incidence of finding an occult hernia varies widely depending on how the surgeon looks for the hernia. One might think that whether a transabdominal preperitoneal (TAPP), robotic TAPP (r-TAPP), totally extraperitoneal (TEP) or extended TEP (e-TEP) approach is used, the incidence of uncovering an unsuspected hernia should be the same. However, the incidence of occult hernia varies widely between published reports, from less than 8% to greater than 50% depending on how surgeons define a hernia and their approach.3,4 In one study, when a transabdominal look was performed followed by a TEP exploration and repair, the incidence increased from 13% to 25%.5 There are two explanations for this difference: One is that the TAPP approach underdiagnoses occult hernias because it misses heniation of extraperitoneal structures

groin pain. The incidence of chronic pain has been reported to be from 6% to 22% in patients undergoing minimally invasive repair.12,13 Further increasing the chances that patients having an occult hernia repaired will develop chronic pain is that bilateral repair has been reported to have a 13% incidence14 and bilateral repair is considered an independent risk factor for developing chronic groin pain.15 like lipomas and the bladder, and the other is that TEP dissection uncovers these extraperitoneal hernias but may overdiagnose occult hernias because it falsely creates them during the dissection. Another study on the TAPP approach divided hernias into actual and incipient, and results suggested the incipient hernias lead to further surgery only 20% of the time and may act differently from true hernias that result in further surgery in 30% of the cases.6 Since most studies don’t differentiate between size or type of occult hernias found, the natural history of occult hernias is further confused. A recent meta-analysis of 13 studies and 5,000 patients suggested one would have to fix 150 occult hernias to prevent 45 future repairs in every 1,000 patients, and 105 patients therefore would undergo the unnecessary risk or morbidity of a repair in a groin that would never require intervention.7 Only 30% of patients with an occult hernia progress to repair in the future8 compared with the 60% to 70% of patients with a clinically apparent hernia as seen in watchful-waiting studies of asymptomatic patients.1,2 Further confusing the decision-making process are studies that have conflicting results. One study suggested we should repair occult hernias because as much as 29% of patients presenting with a unilateral hernia already had the other side repaired,9 but another review found only 6% to 11% of patients who have a hernia repair go on to have the other side repaired.10 To decide whether to treat occult hernias, one must ask what the true denominator and numerator of progression are. To determine if it is worth repairing occult hernias found at the time of a scheduled unilateral minimally invasive repair, we should weigh potential risks, such as early complications, recurrence and chronic pain. Complication rates after minimally invasive inguinal hernia repair vary widely but have been reported to be as high as 10% to 20%,7 and are reported to be higher in patients undergoing bilateral repair.11 Fortunately, most complications, such as seroma, are minor or urinary in origin and resolve without long-term consequences. Recurrence of occult hernias, however, might be expected to occur at the same rate (2%-10%) as primary repairs, and therefore we should not expect the approach of search-and-repair of occult hernias to completely eliminate the need for another surgical intervention as suggested by advocates of the approach. The most important argument against searching for and repairing occult hernias is the risk for causing chronic pain in patients who otherwise would not be at risk. If 70% of occult hernias don’t progress to repair when left untreated, this group is placed at unnecessary risk for developing chronic

My Biased Opinion Is it worth fixing occult hernias or should they just be observed? Unless the incidence of your patients experiencing recurrence or chronic pain approaches zero, I believe the answer is not to fix them. For most of us, a philosophy of repairing occult hernias will result in more problems than benefits for patients and surgeons. Because the majority of occult hernias will never need treatment, they should just be observed. The chances of an occult hernia requiring emergent surgery is rare, as demonstrated by the watchful-waiting studies, and therefore this fear cannot be used as a justification. As far as saving money for the patient and the healthcare system, one must weigh the cost of chronic pain arising in patients who otherwise would remain asymptomatic and never require a repair. I am sure there are some occult hernias that are better repaired when found, but I am just not sure I can identify them with enough accuracy that it outweighs the risk. Unless we have a better data-driven predictor of the natural history of hernia progression, my treatment philosophy remains in the camp of not treating occult hernias. ■

References 1.

Fitzgibbons RJ Jr, Ramanan B, Arya S, et al. Ann Surg. 2013;258(3):508-515.

Chung L, Norrie J, O’Dwyer PJ. Br J Surg. 2011;98(4):596-599.

Novitsky YW, Czerniach DR, Kercher KW, et al. Am J Surg. 2007;193(4):466-470.

Crawford DJ, Hiatt JR, Phillips EH. Am Surg. 1998;64(10):976-978.

Koehler RH. Surg Endosc. 2002;16(3):512-520.

Heuvel B, Beudeker N, Broek J, et al. Surg Endosc. 2013;27(11):4142-4146.

Dhanani NH, Olavarria OA, Wootton S, et al. BJS Open. 2021:5(2):zraa020.

Thumbe V, Evans D. Surg Endosc. 2001;15(1):47-49.

Jarrard J, Arroyo R, Moore T. Surg Endosc. 2012;27(1):11-18.

10. Zheng R, Altieri M, Yang J, et al. Surg Endosc. 2016;31(2):817-822. 11. Jacob D, Hacki J, Bittner R, et al. Surg Endosc. 2015;29(12):3733-3740. 12. Forester B, Attaar M, Chirayil S, et al. Surgery. 2021;169:586-594. 13. Kumar S, Wilson RG, Nixon SJ, et al. Br J Surg. 2002;89(11):1476-1479. 14. Johasen N, Vradl C, Bisgaard T. Scand J Surg. 2020;109(4):289-294. 15. Liu Y, Zhou M, Zhu X, et al. J Anesth. 2020;34(3):330-337.

—Dr. Felix is a general surgeon from Pismo Beach, Calif., and a member of the editorial advisory board of General Surgery News.

What is your opinion on treating occult inguinal hernias? Send your opinion to the editor at khorty@mcmahonmed.com and it will be considered for publication in a future issue.

Hernia Rebranding continued from page 15

have shown that,” Dr. Poulose said. He said more research is needed to see if surgeons are modulating other areas of the abdominal core just by stabilizing the anterior abdominal wall. The concept of abdominal core health is catching on. According to Dr. Poulose, The Ohio State University Wexner Medical Center, Cleveland Clinic, Stonybrook Medicine, Upstate University Hospital, Harvard, Mayo Clinic and Vanderbilt University Medical Center, among others, all have centers of abdominal core health or they incorporate the idea of core function into their approach of taking care of patients. One reason for having a center for abdominal core health is to stand out in the marketplace. “Everybody has a hernia center,” Dr. Poulose said. “Having an abdominal core health center can emphasize the holistic nature of the concept, have multidisciplinary components, and can help with marketing and managing referrals.”

‘Everybody has a hernia center. Having an abdominal core health center can emphasize the holistic nature of the concept, have multidisciplinary components, and can help with marketing and managing referrals.’ —Benjamin Poulose, MD, MPH Rebranding hernia repair as abdominal core health has helped with receiving federal funding. Ohio State University has received funding from the National Institutes of Health for the ADVENTURE-P trial which is going to evaluate whether abdominal core rehabilitation can improve outcomes after ventral hernia repair. “We were funded on the first try,” Dr. Poulose said. Early in my career, I tried to get funding for multiple hernia-related projects and we didn’t even get a response, so certainly something has changed.” Dr. Poulose said he firmly believes that the concept of abdominal core health provides the conceptual model needed for funding agencies to recognize that stabilizing abdominal core function can have a much wider impact on patients’ health than initially thought. “43% of federal grants in hernia [today] have been made possible because of the concept of abdominal core health,” Dr. Poulose said. Rebranding hernia repair as abdominal core health should open up many avenues for younger surgeons. “It opens up avenues for incorporating rehabilitation,” Dr. Poulose said. “It opens up funding needed to investigate whether we are affecting patients beyond the narrow concept of hernia surgery. ... As a group, many have pioneered work in expanding ways of doing our operations robotically, laparoscopically and in open fashion. We need to do equally pioneering work to see if our operations can do more than just fix a hernia. Can we impact the function of related abdominal core components? To me, that is an inspiring thought that I hope will inspire others to dream big.” Many in the hernia field think the rebranding efforts are needed. “I think the rebranding is important and timely, as the concept of holistic/total core health likely represents the future of the field of hernia surgery,” said Richard Pierce, MD, PhD, an assistant professor in the Division of General Surgery at Vanderbilt University Medical Center, and the director of the Vanderbilt Center for Hernia Care and Abdominal Core Health, in Nashville, Tenn. “On one side, we still have to let people know that we are here to help fix their hernia, but the whole rebranding of abdominal core health helps expand that ■ to let people know that we are doing much more.” Dr. Pierce reported no relevant financial disclosures. Dr. Poulose receives salary support from the Abdominal Core Health Quality Collaborative.

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OPINION

GENERAL SURGERY NEWS / APRIL 2022

Grandfather Did It continued from page 1

medicine; in other words, the grandfather did it. I have been a fan of the NFL’s Minnesota Vikings since their inception, and for years was a season ticket holder. In the last few years, my anticipation of their play calling was about 75% accurate. The sideline experts on opposing teams must have done even better. When plays went wrong—which they often did—the commentators, in addition to praising the informed defense, blamed the quarterback for his judgment or passing accuracy, the running back for having been stopped by 800 pounds of muscle, or the receiver for not running the correct route or dropping the ball. Rarely was responsibility placed on the coaching staff who called the plays, until they were fired after the 2021-2022 season. Most rarely did the head coach accept responsibility for the game plan in his post-game press conference. Failure to accept responsibility is commonplace today in the world we live in. When the heads of a large corporation make a bad decision for a subsidiary company, the leadership of the subsidiary is dismissed and criticized for not “properly” carrying out the mandate they had been given. This phenomenon of passing the buck is also manifest in many aspects of our national and local governments. Today, medical academia is very much a replica of the corporate world. Faulty decisions by the “senior leadership,” the dean, the subdeans and the sub-subdeans, are blamed on the department or division heads. In turn, these quasi-leaders try to avoid making innovative decisions in order to stay under the radar and maintain their positions. This abrogation of responsibility is the progenitor of stagnation in healthcare progress. Avoiding responsibility has become the hallmark of today’s practice of healthcare. The first step in this process is evading personal communication. No patient can talk to a doctor by telephone without first talking to robots while listening interminably to elevator music, and eventually being interrogated by a clerk or occasionally a nurse. Few patients, other than those willing and able to pay a ransom for concierge medicine, even have a doctor. Patients rely on a group of interchangeable players with interchangeable hours. They are the recipients of team, group, service-line, committee medical decisions and therapy, wherein each specialist makes a singular contribution to a patient’s care—a process comparable to an industry assembly line. This system has broken the time-honored doctor–patient relationship. Starting with Hippocrates, this relationship has

“Good morning. Doctors no longer make rounds. You have the choice of six screens on your clicker. Press 1 for additional robots, 2 for a physician assistant, 3 for a nurse (possibly), 4 for housekeeping, 5 for interminable music, and 6 for regular television. Have a good day.”

Cartoon by Walter Pories, MD

been based on mutual trust, with a physician taking responsibility for the needs of his or her patient. The terms “my doctor” and “my patient” represent the acceptance of a moral contract. This bond has been broken because it is antithetical to corporate medicine. This abrogation of personal responsibility now exists in our discipline of surgery. The majority of today’s surgeons are employees of a hospital or a healthcare conglomerate, and have traded taking responsibility for individual patients for certain lifestyle advantages. They have become part of service-line medical care under the authority of a CEO or dean.

This abrogation of personal responsibility now exists in our discipline of surgery. The majority of today’s surgeons are employees of a hospital or a healthcare conglomerate, and have traded taking responsibility for individual patients for certain lifestyle advantages. They have become part of service-line medical care under the authority of a CEO or dean. The cardinal assemblies of our profession are the grand rounds and mortality and morbidity (M&M) conferences. In the latter, we discuss our complications and our failures. It is an occasion for all present to learn from mistakes and misjudgments, a teaching opportunity for both surgical neophytes and veterans. This conference pays our respects, at times the last respects, to patients injured by the events being presented. In the past, it was rare for a neighbor at an M&M to say to me, “That’s not the patient I knew,” as the discusser fabricated to cover his or her errors. Fabrication has become more commonplace, as has blaming others or the elements or the system for a technical error, faulty judgment—in essence, any adverse event. Once, after several repeated episodes by a surgical resident of blaming others instead of assuming blame, I rose and said, “It is uncanny that God hates you so much.” This loss of individual ethical standards arises from the existing system of patient care. A confession of error is now cause for a negative grade assessment by the external organizations that determine national standing, and possibly income. A confirmatory, complementary, institutional administrative decision is the policy of avoiding blame for the readmission of a patient with a complication. It is not unusual for a patient returning with an obvious wound infection to be admitted to a nonsurgical service as “a fever of unknown origin,” rather than being readmitted to the surgical service that created the complication. When I was still an active surgeon, I instructed every resident on arriving on my service that I would hold him or her personally responsible for any adverse event that befell a patient in their care. I emphasized this admonition by an example: “If a patient on narcotics or comparable medications falls out of bed at night, it is your fault for not having ordered guardrails.” I was trying to train surgeons to assume responsibility as an ingrained habit for future operative planning, execution and postoperative patient care. When I was in the Strategic Air Command, U.S. Air

Force, the acceptable first response when questioned about a flight incident, or any adverse event, was “My fault, sir!” This practice not only applied to decisions made but in cases where the plane was hit by lightning or the landing gear collapsed. Except for purposeful practice weather flights, lightning clouds could be avoided and landing gears inspected before takeoff. A Board of Inquiry followed an incident, and after a detailed accounting of events, the most common verdict was “Pilot error.” This standard policy for inculcating personal responsibility was designed to provide the nation with responsible service officers. The basic education of a surgeon takes 13 years: four years of college, four years of medical school, five years of residency, which is commonly augmented by two to five additional years of fellowship or research—for a potential total of 15 to 18 years. At this point, the surgical trainee is in his or her 30s, and may have a growing family. What is the universal graduation gift, besides financial concerns, for the newly designated, probably board-certified surgeon? It is independence— that is, taking responsibility for one’s actions. For a surgeon, this independence is exemplified by stepping into the operating room for the first time with no attending surgeon for cover. Such a precious gift should not readily be denigrated by servitude to an administrative body. With this gift of personal independence comes the acceptance of responsibility for others. If independence is forfeited, responsibility for decisions, actions and outcomes also perishes. What does this gift of independence generate in addition to the best patient care? It is the basis for surgical progress. In the 30 years from 1930 to 1960, at the University of Minnesota Department of Surgery (“fly-over land” to many), under the leadership of Owen H. Wangensteen, the following occurred: reduction in mortality for bowel obstruction from 40% to 4%; the introduction of open-heart surgery using a pump oxygenator, the basis for heart transplantation; the first pancreas transplantation; the partial ileal bypass operation for hyperlipidemia; the background studies for the first National Institutes of Health–funded randomized controlled trial using metabolic surgery that demonstrated atherosclerosis retardation and regression; the first bariatric surgery procedures; and other surgical contributions. These halcyon days have been documented in a book titled “Surgical Renaissance in the Heartland: A Memoir of the Wangensteen Era” (Buchwald H. University of Minnesota Press; 2020). In this article, I have tried to provide some thoughts for reflection and a perspective on personal responsibility. The concept of “Grandfather did it” is not limited to the ROC; it has become commonplace in our everyday world. It dominates our healthcare delivery and has invaded our discipline of surgery. Can we reestablish professional independence and responsibility? Do we, ■ as a discipline, want to? —Dr. Buchwald is a professor of surgery and biomedical engineering, and the Owen H. and Sarah Davidson Wangensteen Chair in Experimental Surgery (emeritus), at the University of Minnesota, in Minneapolis. His articles appear every other month. Editor’s note: Opinions in General Surgery News belong to the author(s) and do not necessarily reflect those of the publication.

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