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  • www.acssurgery.com WILEY W. SOUBA, MD, ScD, FACS, Editorial Chair DOUGLAS W. WILMORE, MD, FACS, Founding Editor July 2008 THE BEST THIS MONTH’S UPDATES SURGICAL 2 Head and Neck the earlobe), and finally turns downward to descend along the THINKING 6 Parotidectomy LEONARD R. HENRY, MD, AND JOHN A. sternocleidomastoid muscle. Skin flaps are then created to expose the parotid gland. The posterior-inferior The Fundamentals of RIDGE, MD, PHD, FACS skin flap is then elevated in a similar manner. Laparoscopic Surgery (FLS) National Naval Medical Center, Once the skin flaps have been Program: Its Time Has Come! Uniformed Services University of the developed and retracted, the next Health Sciences; Fox Chase Cancer step is to identify the facial nerve. NATHANIEL J. SOPER, MD Center, Temple University School of Usually, the nerve may be identified Department of Surgery, Medicine either at its main trunk (the ante- Northwestern University Feinberg DOI 10.2310/7800.S02C06 grade approach) or at one of the School of Medicine distal branches, with subsequent Most parotid tumors are benign, dissection back toward the main DOI 10.2310/7800.2008.NCjul necessitating only superficial trunk (the retrograde approach). For he incorporation of laparoscopic parotidectomy. T surgery into the armamentarium he parotid gland, the largest of a lateral parotidectomy, our preference is to identify the main of general surgeons occurred rapidly in the early 1990s. There was a T the salivary glands, occupies the space immediately anterior to the trunk first (unless it is thoroughly obscured by tumor or scar), keeping distinct “learning curve” during the ear, overlying the angle of the in mind that the nerve typically lies uptake of laparoscopic cholecystec- mandible. The portion of the deeper than one might expect. tomy, with an increase in bile duct parotid gland lateral to the facial Once identified, the plane of the injuries.1 Much of the education nerve (about 80% of the gland) is facial nerve remains uniform offered on laparoscopic techniques designated as the superficial lobe; throughout the gland (unless the for established surgeons was the portion medial to the facial nerve is displaced by a tumor) and provided by industry, and many nerve (the remaining 20%) is serves to guide the parenchymal surgeons learned “one-handed” designated as the deep lobe. dissection, which proceeds directly operating techniques, whereas the Deep lobe tumors often present over the facial nerve. We do not underpinning cognitive aspects clinically as retromandibular or continued on page 3 unique to laparoscopy were given parapharyngeal masses, with short shrift. In the late 1990s, the displacement of the tonsil or the soft Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) palate appreciated in the throat. The overwhelming majority of parotid In This Issue began developing the Fundamentals tumors, however, are benign and The Best Surgical Thinking of Laparoscopic Surgery (FLS), a lateral to the facial nerve. This The Fundamentals of Laparoscopic program designed to cover the chapter focuses primarily on Surgery (FLS) Program: Its Time Has cognitive and psychomotor aspects superficial parotidectomy. Come! 1 unique to laparoscopic surgery, 2 Head and Neck associated with a mechanism for Operative Technique for 6 Parotidectomy 1 assessment. It was not SAGES’ Parotidectomy 2 Head and Neck he incision begins immediately 9 Thyroid and Parathyroid Operations 4 intent to develop a certifying examination but rather to provide T anterior to the ear, continues downward past the tragus, curves 4 Thorax 8 Minimally Invasive Esophageal continued on page 2 back under the ear (staying close to Procedures 4
  • 2 What’s New in ACS Surgery • July 2008 www.acssurgery.com THE BEST SURGICAL THINKING continued from page 1 Owned and published by BC Decker Inc tools for the teaching and assess- are transferable to the operating ment of the cognitive knowledge, room environment.4,5 EDITORIAL CHAIR: Wiley W. Souba, MD, SCD, FACS, Columbus, OH technical skills, and clinical judg- After developing the teaching and FOUNDING EDITOR: ment related specifically to basic evaluation modules of the FLS Douglas W. Wilmore, MD, FACS, Boston laparoscopic surgery. The final program, it was subjected to beta EDITORIAL BOARD: product was the result of the testing at seven designated centers. Mitchell P. Fink, md, facs, Pittsburgh Gregory J. Jurkovich, md, facs, Seattle Larry R. Kaiser, combined effort by many surgical Surgical trainees from different md, facs, Philadelphia William H. Pearce, md, experts, educators, and administra- levels and practicing surgeons took facs, Chicago John H. Pemberton, md, facs, Rochester, MN Nathaniel J. Soper, md, facs, tors and represents one of the first part in this evaluation, which has Chicago fully developed competency evalua- been reported elsewhere.3 The beta COUNCIL OF FOUNDING EDITORS: tion tools available for surgeons.2,3 test results for the FLS examination Murray F. Brennan, md, facs, New York The FLS program consists of two demonstrated satisfactory reliability, Laurence Y. Cheung, md, facs, Kansas City Alden H. Harken, md, facs, San Francisco components: a teaching module for appropriate psychometric proper- James W. Holcroft, md, facs, Sacramento education and an examination to ties, and substantial validity. Jonathan L. Meakins, md, dsc, facs, Oxford assess competency. The cognitive In 2005, the American College of PUBLISHER: portion includes didactics in four President, Brian C. Decker Surgeons (ACS) partnered with Vice President, Sales, Rochelle J. Decker broad content areas: preoperative SAGES to lend support to this first Vice President and Publisher, Liz Pope considerations, intraoperative fully developed competency evalua- Managing Editor, Susan Cooper Manager, Special Sales, Jennifer Coates considerations, basic laparoscopic tion tool available for surgeons. Manager, Customer Care and Distribution, Marie procedures, and postoperative Since that time, great momentum Moore Rights and Permissions, Paula Mucci considerations. The content was has developed around the FLS Director, Digital Publishing, David Love heavily vetted among experts in program. Many general surgery Electronic Media Systems Analyst, Jeff Ferguson Senior Web/IT Developer, Faisal Shah laparoscopy for being essential for residency programs have incorpo- ACS Surgery: Principles & Practice (bound basic laparoscopic surgery. The rated FLS as a key component of volume: ISBN 978-1-55009-399-5; CD-ROM: second portion of the training laparoscopic training. The joint ISBN 978-1-55009-421-3; quarterly CD ROM: outlines the manual skills training ISSN 1538-3210; online: ISSN 1547-1616) is ACS-APDS (Association of Program owned and published by BC Decker Inc, 50 King practicum based on a training Directors in Surgery) technical skills St. E., 2nd Floor, PO Box 620, LCD1, Hamilton, program developed by Fried and curriculum includes the components ON L8N 3K7, Canada, Web site: http://www. bcdecker.com. © 2008 BC Decker Inc. All rights colleagues at McGill University.4,5 of the FLS program in its laparo- reserved. No part of this issue may be reproduced This module includes five “watch scopic modules. Several hospitals by any mechanical, photographic, or electronic process or in the form of a phonographic and do” exercises, which are have mandated that surgeons recording, nor may it be stored in a retrieval measurable and designed to allow practicing laparoscopic surgery must system, transmitted, or otherwise copied for public or private use without written permission students to practice and improve have passed the FLS examination to of the publisher. their laparoscopic skills. be privileged to perform laparos- Annual subscription rates in Canada and the “Competence” is assessed through copy. At least one captive malprac- USA: Quarterly CD-ROM: $209 (individual), $709 (institutional); Online: $189 (individual). a two-part examination. The tice insurance company has incentiv- Institutional Web site license pricing available on cognitive examination consists of a ized participating surgeons to attain request. Please e-mail acssurgery@bcdecker.com. timed, secure test with multiple- FLS certification. There has also Separate shipping and handling apply. All prices subject to change without notice and quoted in choice questions and clinical been increased interest in the FLS US dollars. scenarios. These questions and program from international sur- POSTMASTER: Send address changes to BC Decker Inc, PO Box 758, Lewiston, NY 14092- scenarios were subjected to rigorous geons. For instance, the Royal 0785. oversight by medical educators2,3 Australasian College of Surgeons FOR ASSISTANCE WITH YOUR SUBSCRIPTION and were designed to withstand has now incorporated FLS into its Please address all inquiries to Fulfillment Department, “high-stakes” scrutiny. The manual training programs and board BC Decker Inc, P.O. Box 758, Lewiston, NY 14092- skills test assesses five basic tech- certification process. 0785, or call us at 905-522-7017 or 800-568-7281, or fax us at 905-522-7839 or 888-311-4987, or email us niques (peg transfer, pattern cutting, Despite these initiatives, there was at acssurgery@bcdecker.com. For change of address, ligating loop, intracorporeal knot, concern that the price of the FLS please provide both your new and your old addresses; be sure to notify us at least six weeks before you extracorporeal knot) based on program is prohibitive for most expect to move to avoid interruptions in your service. efficiency and precision. This general surgery residencies. In YOUR FEEDBACK IS WELCOME examination is proctored, taken on response to this concern, the • E-mail: acssurgery@bcdecker.com standardized training boxes with Covidien Corporation recently • Write: BC Decker Inc P.O. Box 620, LCD1 uniform equipment, and occurs at funded a large educational grant to Hamilton, ON L8N 3K7 designated testing locations. This SAGES to allow rapid dissemination Canada manual skills test has been subjected among surgical training programs. to extensive validation by the This generous grant will allow each McGill group; the scores correlate with laparoscopic experience and continued on page 3 www.acssurgery.com
  • www.acssurgery.com What’s New in ACS Surgery 3 This Month’s CME THIS MONTH’S UPDATES continued from page 1 Chapters regularly resect the entire lateral mandible and may reach a signifi- ACS Surgery offers CME in lobe of the parotid gland unless the cant size in patients with large or convenient online format. As tumor is large and such resection is recurrent tumors. Strictly speaking, many as 60 AMA PRA Category required on oncologic grounds. this cosmetic change is a necessary 1 credits can be earned at Complete superficial parotidec- feature of the procedure, not a any time during the year. The tomy with full dissection of all facial complication. following chapters are available nerve branches is seldom necessary, for CME credit this month: although, in some cases, it is mandated by tumor size or histo- Outcome Evaluation of 2 Head and Neck 6 Parotidectomy logic findings. The question of Parotidectomy 2 Head and Neck whether to sacrifice the facial nerve ith proper surgical technique, almost invariably arises in the setting of malignancy. In our view, W superficial or partial superficial parotidectomy can be performed 9 Thyroid and Parathyroid Operations 4 Thorax 8 Minimally Invasive Esophageal this measure is seldom necessary. safely and within a reasonable Procedures Benign tumors tend to displace the operating time. nerve, not invade it. Sacrifice of the nerve probably does not enhance survival. Before closure, absolute hemosta- sis is confirmed. Facial nerve function is evaluated in the recovery room, with particular attention paid THE BEST SURGICAL THINKING continued from page 2 to whether the patient is able to close the eyelid. general surgery resident training surgery trainees, the FLS program program in the United States and should achieve wide dissemination Canada to obtain one of the FLS and improve the safety of patients Complications of video training boxes as part of their undergoing laparoscopic surgery. Parotidectomy Residency Review Committee- mandated simulation effort. Fur- tudies have found that transient References S paralysis of all or part of the facial nerve occurs in 17 to 100% of thermore, vouchers for completing the testing component of FLS will be 1. Strasberg SM, Hertl M, Soper supplied for each graduating chief NJ. An analysis of the problem patients undergoing parotidectomy, resident in general surgery and to of biliary injury during laparo- depending on the extent of the fellows in gastrointestinal surgery scopic cholecystectomy. J Am resection and the location of the fellowships. Notices have gone out Coll Surg 1995;180:101–25. tumor. Fortunately, permanent to all program directors informing 2. Peters JH, Fried GM, Swanstrom paralysis is uncommon, occurring in them of the ability to obtain these LL, et al. Development and fewer than 5% of cases. The resources. It thus seems likely that validation of a comprehensive primary complications are gustatory FLS will be incorporated in virtually program of education and sweating, sialocele, and cosmetic all North American training assessment of the basic funda- changes. programs. mentals of laparoscopic surgery. Gustatory sweating, or Frey In summary, the FLS program was Surgery 2004;135:21–7. syndrome, occurs in most patients developed because of an identified 3. Swanstrom LL, Fried GM, after parotidectomy; it has been seen need to educate surgeons in the Hoffman KI, Soper NJ. Beta test after submandibular gland resection underlying principles and basic skills results of a new system assessing of laparoscopic surgery and because competence in laparoscopic as well. The symptom complex of the growing demand to document surgery. J Am Coll Surg includes sweating, skin warmth, and competency in surgical practice. The 2006;202:62–9. flushing after chewing food and is 4. Derossis AM, Fried GM, Abra- program has been extensively vetted caused by cross-innervation of the by experts and validated in beta hamowicz M, et al. Development parasympathetic and sympathetic testing. The inclusion of a testing of a model for training and fibers supplying the parotid gland component ensures that competency evaluation of laparoscopic skills. and the overlying skin. Sialocele, or in laparoscopy is both taught and Am J Surg 1998;15:482–7. salivary fistula, has been reported evaluated. Given the partnership 5. Fried GM, Feldman LS, Vassiliou to occur after 1 to 15% of paroti- with the ACS, the growing recogni- MC, et al. Proving the value of dectomies. Parotidectomy creates a tion of FLS internationally, and the simulation in laparoscopic hollow anterior and inferior to the recent Covidien grant allowing surgery. Ann Surg ear, which may extend behind the widespread adoption by general 2004;240:518–28.
  • 4 What’s New in ACS Surgery • July 2008 www.acssurgery.com THIS MONTH’S UPDATES continued from page 3 2 Head and Neck mobilization of the lower thyroid Complications of pole. The carotid sheath is retracted laterally, and the thyroid gland is Thyroidectomy 9 Thyroid and Parathyroid he most significant complications Operations retracted anteriorly and medially. This retraction puts tension on the inferior thyroid artery and conse- T of thyroidectomy are injury to the recurrent laryngeal nerve, hypopara- WEN T. SHEN, MD, GREGG H. JOSSART, quently on the recurrent laryngeal thyroidism, bleeding, injury to the MD, FACS, AND ORLO H. CLARK, MD, nerve, thereby facilitating identifica- external branch of the superior FACS tion of the nerve. The right and left laryngeal nerve, infection, seroma, University of California, San recurrent laryngeal nerves must be or keloid. Francisco; California Pacific Medical preserved during every thyroid Center, San Francisco; University of operation. In identifying the recurrent laryngeal nerves, it is Parathyroidectomy California, San Francisco he preparation for DOI 10.2310/7800.S02C09 helpful to remember that they are supplied by a small vascular plexus and that a tiny vasa nervorum runs T parathyroidectomy is similar to that for thyroidectomy. The gold The operative techniques for parallel to and directly on each standard operation for primary thyroidectomy and parathyroidec- nerve. hyperparathyroidism remains bilateral tomy are similar, and avoiding The pyramidal lobe (found in about neck exploration; however, the injury of the laryngeal nerves is 80% of patients) is mobilized by excellent results of preoperative paramount. retracting it caudally and by dissect- imaging with sestamibi scanning and ing immediately adjacent to it in a ultrasonography, coupled with the Operative Technique for cephalad direction. Once the availability of rapid intraoperative parathyroid glands have been Thyroidectomy carefully swept or dissected from the parathyroid hormone assays, have efore thyroidectomy, laryngoscopy made unilateral focused exploration B is essential to determine whether the vocal cords are functioning thyroid gland and the recurrent nerve has been identified, the thyroid lobe can be quickly resected. feasible for well-localized parathyroid adenomas. The complications of normally. Thereafter, as a rule, parathyroidectomy are similar to dissection should always begin on those of thyroidectomy but occur Special Concerns of less often. the side of the suspected tumor; if there is a problem with the dissec- Thyroidectomy tion on this side, a less than total n rare occasions, thyroid or thyroidectomy can be performed on the contralateral side to prevent O parathyroid cancers may invade the trachea or the esophagus. As 4 Thorax complications. The thyroid gland is much as 5 cm of the trachea can be 8 Minimally Invasive exposed via a midline incision resected safely without impairment Esophageal Procedures through the superficial layer of deep of the patient’s voice. If the invasion cervical fascia between the strap is not extensive and is confined to FRANCESCO PALAZZO, MD, PIERO M. muscles. However, if they are the anterior portion of the trachea, a FISICHELLA, MD, AND MARCO G. PATTI, adherent to the underlying thyroid small section of the trachea that MD, FACS tumor, the portion of the muscle contains the tumor should be adhering to the tumor should be excised, and a tracheostomy may be University of California, San sacrificed and removed en bloc with placed at the site of resection. Francisco; Loyola University the specimen. Lymph nodes in the central neck Medical Center, Chicago; University When a thyroid lobectomy is (medial to the carotid sheath) are performed, the isthmus of the frequently involved in patients with continued on page 5 thyroid gland is usually divided papillary, medullary, and Hürthle lateral to the midline, taking care not to cut across the tumor. Once cell cancer. These nodes should be removed without injury to the Coming in August the isthmus has been divided, parathyroid glands or the recurrent Elements of Contemporary Practice dissection is continued superiorly, laryngeal nerves. A median sternoto- 8 Health Care Economics: laterally, and posteriorly. It is my is rarely necessary for removal of The Broader Context essential to avoid injuring the the thyroid gland, but if one proves 1 Basic Surgical and Perioperative external branch of the superior necessary, the sternum should be Considerations laryngeal nerve (responsible for divided to the level of the third 9 Ambulatory and Fast-Track Surgery tensing the vocal cords). intercostal space and then laterally 8 Critical Care The lower parathyroid gland is on one side at the space between the 22 Nutritional Support usually encountered during lateral third and fourth ribs.
  • www.acssurgery.com What’s New in ACS Surgery 5 of Chicago Pritzker School of fundoplication as for Nissen generally comparable to those Medicine fundoplication, and many of the obtained with corresponding open surgical steps are the same. Over the surgical procedures. Delayed DOI 10.2310/7800.S04C08 years, however, it has become esophageal leakage is a common Treating benign esophageal evident that a partial fundoplication postoperative complication. disorders with minimally invasive is not as durable as a total fundopli- laparoscopic procedures yields cation. As a result, total fundoplica- results comparable to those of Reoperation for GERD tion is currently considered the urrently, an increasing number of treatment with traditional operations. procedure of choice for patients with GERD, regardless of the C patients are being seen for evaluation and treatment of foregut he development of laparoscopic strength of their esophageal T surgery over the past 20 years has caused a significant shift in the peristalsis. symptoms after laparoscopic antireflux surgery. If the symptoms persist or heartburn and regurgita- treatment of benign esophageal Laparoscopic Heller tion occur, a thorough evaluation diseases. Consequently, minimally (with barium swallow, endoscopy, invasive surgery is increasingly Myotomy with Partial esophageal manometry, and pH considered first-line treatment for Fundoplication monitoring) is carried out. achalasia, and laparoscopic fundopli- oday, laparoscopic Heller We do not routinely attempt a cation is considered more readily and at an earlier stage to manage gastro- T myotomy with partial fundoplica- tion has supplanted left thoraco- second antireflux operation laparo- scopically, and the optimal proce- esophageal reflux disease (GERD). scopic myotomy as the procedure of dure depends on the original Here we focus on the operative choice for esophageal achalasia. approach (open versus laparoscop- procedures for the most common Candidates should undergo a ic), the severity of the adhesions, minimally invasive approaches. and the specific technique used for thorough and careful evaluation to establish the diagnosis and charac- the first operation (total or partial Laparoscopic Nissen terize the disease. Many of the steps fundoplication). Because the risk of gastric or esophageal perforation or Fundoplication in a laparoscopic Heller myotomy damage to the vagus nerves is much ll candidates for laparoscopic are the same as the corresponding A fundoplication should undergo (1) symptomatic evaluation, with steps in a laparoscopic fundoplica- tion; intraoperative endoscopy is higher during a second antireflux operation, the surgeon must proceed with extreme care, making sure to symptoms graded with respect to where the operative technique identify structures completely before their intensity both before and after differs, and great care must be taken dividing them. The success rate falls the operation; (2) an upper gastroin- not to perforate the esophagus. The to 70 to 80% for a second such testinal series, to diagnose an results obtained to date with operation. existing hiatal hernia; (3) endos- laparoscopic Heller myotomy and copy, to confirm a symptom-based partial fundoplication are excellent diagnosis of GERD; (4) esophageal and are generally comparable Reoperation for Esophageal manometry, which provides useful to those obtained with the Achalasia information about the motor corresponding open surgical aparoscopic Heller myotomy function of the esophagus; and (5) ambulatory pH monitoring, the procedure. L improves swallowing in more than 90% of patients. What causes most reliable test for the diagnosis Left Thoracoscopic the relatively few failures reported is of GERD. Once the operation is still incompletely understood. complete, the greatest complication Myotomy Typically, a failed Heller myotomy urrently, we consider a left is esophageal or gastric perforation. Optimal management consists of C thoracoscopic myotomy for patients in whom multiple previous is signaled either by persistent dysphagia or by recurrent dysphagia laparotomy and direct repair. that develops after a variable abdominal procedures (done to treat symptom-free interval following the other diseases) would preclude a original operation. There are two Laparoscopic Partial laparoscopic approach. Preoperative treatment options for persistent or (Guarner) Fundoplication evaluation is essentially the same recurrent dysphagia after Heller reoperative evaluation and as that for laparoscopic Heller P operative planning are essentially the same for partial (Guarner) myotomy. The results obtained with thoracoscopic myotomy are myotomy: pneumatic dilatation and a second operation tailored to the results of preoperative evaluation.