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PubMedDate not supplied

Laparoscopic surgery in the pregnant patient--one surgeon's experience in a small rural hospital.

OBJECTIVES: The laparoscopic treatment of urgent surgical conditions that develop in pregnant patients has not been extensively addressed in the current literature. It is a potential issue to which surgeons, especially rural surgeons, should give careful consideration, prior to being faced with an urgent situation during the delivery process. This report details 1 surgeon's experience over a 5-year period with laparoscopic surgery in the pregnant patient, primarily laparoscopic cholecystectomy, at a small rural Nebraska hospital. METHODS: Eleven laparoscopic operations were conducted in 10 patients. RESULTS: One patient underwent 2 separate operations: cholecystectomy at 6 weeks gestation and reduction of ovarian torsion/appendectomy at 20 weeks. One patient, at term, underwent combination cesarian delivery and laparoscopic cholecystectomy. Three patients underwent laparoscopic cholecystectomy during their third trimester of pregnancy. All patients had severe signs and symptoms that threatened successful term gestation and/or failed attempts at conservative medical management aimed at delaying cholecystectomy until after delivery. One complication occurred involving uterine perforation with a blunt 10-mm port canula. No fetal injury occurred, and after initial recovery from the cholecystectomy, the baby was successfully delivered later in the pregnancy via cesarian delivery without adverse sequelae. CONCLUSION: Urgent laparoscopic operations can be carried out successfully in pregnant patients throughout their pregnancy, even in remote locations lacking immediate on-site availability of subspecialty care. The surgeon must be skilled in surgical obstetrics and well trained and experienced in advanced laparoscopic techniques. It is recommended that the same lines of communication and referral for subspecialty involvement be in place as would be required in the management of premature delivery of pregnant patients without surgically urgent disease. Such lines of communication should be developed before the actual need arises. The rural surgeon must have a plan of action well in advance of that first encounter or any subsequent complication.

Adolescent↗
PubMed2002

Evaluation of patients with clinically suspected melanoma recurrence: current practice patterns of plastic surgeons.

The optimal extent-of-disease evaluation for patients with clinically suspected melanoma recurrence is not known. The available modalities are numerous and many are expensive. We documented the extent of work-up carried out by plastic surgeons when their patients with melanoma develop clinical recurrence. A custom-designed questionnaire was mailed to a random sample (n=3,032) of the 4,320 members of the American Society of Plastic and Reconstructive Surgeons (ASPRS). Subjects were asked which specific laboratory tests and imaging studies they would order for a patient with initial T2N0M0 disease treated with curative intent who later presented with either regional nodal metastases or pulmonary metastases. We measured the variability in practice patterns among surgeons and estimated the effects of physician age, U.S. census region, health maintenance organization (HMO) penetration rates, and type of recurrence (regional versus systemic) on work-up intensity. Of the 1,142 questionnaires completed (38%), 395 (35%) were evaluable. Non-evaluability was usually due to lack of melanoma patient follow-up in surgeons' practices. Lesion biopsy, chest X-ray, complete blood count, liver function tests, and computed tomography were frequently used, but there was no consensus for most modalities. More tests, particularly computed tomography, were utilized for evaluating systemic recurrence than for regional recurrence (p<0.05). The intensity of work-up differed significantly (p<0.05) by surgeon age for three diagnostic tests but not by U.S. census region or HMO penetration rate. This is the first empirical data on this subject from a large sample of an international society of highly credentialed experts. The lack of consensus for most tests in current practice is presumably due to multiple factors, including the lack of evidence supporting any particular strategy.

Adult↗
PubMed2002

Influence of surgeon's volume on early outcome after total gastrectomy.

OBJECTIVE: To examine correlation between number of total gastrectomies done by each of 21 surgeons and the early outcome of these operations. DESIGN: Retrospective case series. SETTING: University hospital, Japan. PATIENTS: 136 patients treated by total gastrectomy for gastric cancer during a 4-year period. INTERVENTION: Univariate and multivariate analyses of the effect of each surgeon's volume on the early outcome of total gastrectomy. MAIN OUTCOME MEASURES: Differences in the morbidity and mortality after total gastrectomy between high-volume and low-volume surgeons. RESULTS: There was a significant difference in the incidence of major complications of total gastrectomy between high-volume (7/66, 11%) and low-volume (17/70, 24%) surgeons (p = 0.04). CONCLUSION: Possible reasons for differences in outcome between high-volume and low-volume surgeons should be investigated in an attempt to define and describe the methods that are associated with the best outcome.

Adult↗
PubMed2004

[Improving the surgeon's image: introduction].

The number of medical students who aspire to become surgeons has been decreasing in recent years. With a vicious spiral in the decreasing number and the growing deterioration of surgeons' working conditions, there is fear of deterioration of surgical care and subsequent disintegration of overall health care in Japan. The purpose of this issue is to devise a strategy for improving surgeons' image and their working conditions to attract future medical students. However, we cannot expect a quick cure for the problem of the decreasing number of applicants for surgery since this issue is deeply related to many fundamental problems in the health care system in Japan. The challenge for surgical educators in coming years will be to solve the problem of chronic sleep deprivation and overwork of surgery residents and to develop an efficient program to meet the critical educational needs of surgical residents. To solve this problem it is necessary to ensure well-motivated surgical residents and to develop an integrated research program. No discussion of these issues would be complete without attention to the allocation of scarce medical resources, especially in relation to financial incentives for young surgeons. The authors, who are conscientious representatives of this society, would like to highlight these critical problems and issues that are particularly relevant to our modern surgical practice, and it is our sincere hope that all members of this society fully recognize these critical issues in the Japanese health care system to take leadership in improving the system. With the demonstration of withholding unnecessary medical conducts we may be able to initiate a renewal of the system and eventually to fulfill our dreams of Japan becoming a nation that can attract many patients from all over the world. Furthermore, verification of discipline with quality control and effective surgical treatment is needed to avoid criticism by other disciplines for being a self-centered field. The Japanese Surgical Society appears to be the only medical society that is capable of leading a revolution in the health care system of this country with its autonomy and self-discipline. It is timely for the Japanese Surgical Society to consider a modification of its stated mission by adding "to improve the care of the surgical patient" as dictated by the American College of Surgeons.

Attitude of Health Personnel↗
PubMed2004

[Patient's pain feeling and surgeon's comfort--ECCE versus phacoemulsification].

PURPOSE: To compare patient's pain and surgeon's comfort during ECCE performed under retrobulbar anesthesia and phacoemulsification under topical anesthesia. MATERIAL AND METHODS: 120 patients scheduled for planned routine cataract extraction were divided in 2 groups: group 1-60 eyes, ECCE under retrobulbar anesthesia and group II-60 eyes, phacoemulsification under topical anesthesia. Immediately after operation patients were asked, to answer questions about their feeling during surgery. Simultaneously, the surgeon filled up the questionnaire, concerning patients behavior during the entire procedure. RESULTS: Statistically significant higher level of pain was reported in group I (ECCE). The most painful moment of the procedure was retrobulbar injection. During surgery pain feeling in both groups was similar. Both types of anesthesia provided very good level of surgeon's comfort. The longer operation, the higher level of pain and lower surgeon's comfort were reported in both groups. CONCLUSIONS: Patients having ECCE performed under retrobulbar anesthesia reported more pain comparing to phacoemulsification under topical anesthesia. Both anesthesia methods provided high level of surgeon's comfort.

Aged↗
PubMed2005

[Surgeons among the pirates in the 17th century].

The memoirs of ship's surgeons that sailed with the Caribbean buccaneers and pirates of the 17th century are an important source of information on how they lived and worked. The surgeons enjoyed a full-fledged position among the egalitarian buccaneers. Known buccaneer surgeons whose memoirs have been preserved were apparently not entirely qualified according to the traditional guild system. Besides the usual work of ship's surgeons in general, the buccaneer surgeons had to be able to cope with the specific demands of the tropical climate. Botanical knowledge obtained from the Indian tribes played an important role in surviving the jungles of Central America. In addition, they were required to assist with duels, which played an important role among pirates and buccaneers in the settling of conflicts aboard ship, this in contrast to the situation on merchant and navy ships.

General Surgery↗
PubMed2005

Colorectal cancer screening: practices and attitudes of gastroenterologists, internists and surgeons.

BACKGROUND: The Canadian Task Force on Preventive Health Care has recommended the use of annual or biennial fecal occult blood testing (FOBT) and flexible sigmoidoscopy in the periodic health examination of asymptomatic people over 50 years of age. Therefore, we decided to ascertain the current colorectal cancer (CRC) screening practices and attitudes of surgeons, gastroenterologists and internists. METHODS: In June 2002 (with a final mailing in December 2002), a questionnaire was sent to all gastroenterologists, internists and surgeons in Alberta. It included items on demographic and practice characteristics, CRC screening practices and opinions about CRC screening. RESULTS: Responses were received from 42 gastroenterologists, 83 internists and 68 surgeons. Overall, 141 of 187 respondents (75.4%, 95% confidence interval [CI] 68.6%-81.4%) recommended that average-risk adults undergo CRC screening. Internists were less likely to recommend screening than either gastroenterologists or surgeons (95% CI for the difference 7.2%-32.8%). The most commonly recommended screening test was colonoscopy (70%), followed by FOBT (65%), flexible sigmoidoscopy (47%) and air-contrast barium enema (31%). Colonoscopy was the only test recommended by 7 (22.6%) of 33 gastroenterologists, 9 (16.4%) of 59 surgeons and 3 (6.1%) of 49 internists. Respondents were more likely to list barriers to the use of colonoscopy (mean 5 barriers) for screening than for either FOBT or flexible sigmoidoscopy (mean 2 barriers for both tests). Only 3 respondents indicated that they themselves would not undergo screening. Colonoscopy was the only screening test that 135 (70.0%) of the 193 would themselves undergo. CONCLUSIONS: The majority of Alberta specialists recommend CRC screening for average-risk adults. Colonoscopy was the most commonly recommended test, despite the perception of more barriers to that technique and the 2001 guidelines prepared by the Canadian Task Force for Preventive Health Care, which did not support colonoscopy.

Adult↗
PubMed2006

The practice of conscious sedation by Senior Dental Surgeons in the Health Board Dental Service in the Republic of Ireland.

OBJECTIVE: To establish the nature and extent of the practice of conscious sedation by Senior Dental Surgeons in the Health Board Dental Service (HBDS) in the Republic of Ireland and to determine the barriers to the use of conscious sedation. DESIGN: Postal questionnaire survey. SETTING: The Health Board Dental Service in the Republic of Ireland in 2002. SUBJECTS AND MATERIALS: Questionnaires were sent to fifty-five Senior Dental Surgeons working in the HBDS. RESULTS: Fifty questionnaires (90.9%) were returned. Less than a quarter of Senior Dental Surgeons reported current sedation use in their area. Oral sedation was the most commonly used method with few using relative analgesia and less using intravenous sedation. Forty percent of Senior Dental Surgeons surveyed reported receiving training in conscious sedation as an undergraduate. Nearly 60% of those surveyed reported using conscious sedation in a previous employment. All respondents said the main barrier to the use of conscious sedation in the HBDS was the lack of training opportunities on the subject in Ireland. CONCLUSIONS: Conscious sedation techniques other than oral, are used to a very limited extent in the HBDS in Ireland. There is great interest amongst Senior Dental Surgeons in the increased use of conscious sedation techniques. A lack of training opportunities is the main barrier to the expansion of their use.

Adult↗
PubMed2006

The practicing surgeon as a member of the quality-safety team.

The practicing surgeon is a valuable member of the quality-safety team and is often an underutilized data source for quality initiatives. The authors describe how their efforts in Kentucky, during a 10-year period, encouraged surgeons to become leaders in the quality initiative. Their experience began with the establishment of an organization of surgeons devoted to quality health care and cost control. As their efforts expanded and they gained experience, they were well prepared to transition to a regional and national quality initiative as part of a collaborative effort with the Centers for Medicare and Medicaid Services in the 2004 Surgical Care Improvement Project pilot. As a result of this ongoing experience, the authors we have been able to affect the quality of health care and have a positive influence on health care cost. They have demonstrated that surgeons will participate in and lead quality initiatives, and that these efforts foster an environment of cooperation between surgeons and hospitals.

General Surgery↗
PubMed2006

[Assessment of HBV, HCV and HIV injection in a population of Polish orthopedic surgeons].

UNLABELLED: Orthopedic surgeons are at risk for occupationally acquired infections with blood borne pathogens. OBJECTIVE: To estimate the prevalence of infection with HBV, HCV, CMV and HIV among orthopedic surgeons. DESIGN: Voluntary, anonymous serosurvey at an annual meeting of Polish Association of Orthopedic Surgeons held in Szczecin, Poland in 2004. Serum samples were tested for anti-HIV, anti-CMV IgG, anti-HCV and markers of HBV infection: anti-HBc total and HBs. RESULTS: Of 1000 eligible orthopedic surgeons at the meeting, 101 (10.4%) participated; 75% participants reported a percutaneous blood contact in the previous month. None of the doctors was positive for HIV (0%, 95% CI:0-3.7%). One participant (1%, 95% CI: 0.2-5.4%), 26 years in profession, had anti-HCV. There was evi-dence of infection with HBV in 10 of 96 participants (10.4%) who had reported having no nonoccupational risk factors and in 5 participants with such factors. None of them developed a chronic infection. Only 5 out of 15 doctors infected with HBV knew their serological status, 13 out of those 15 had been immunized with hepatitis B vaccine, 4 revaccinated. The immunization rate was 91%. The seroprevalence for CMV was 63/101 (62%); it increased with age (p < 0.0003). CONCLUSIONS: Despite infection control precautions and availability of hepatitis B vaccine, orthopedic surgeons remain at risk for acquiring bloodborne viral infection. CMV poses the highest risk, followed by HBV and HCV. As the majority of HBV infected doctors did not know their serological status and underwent immunization with hepatitis B vaccine, testing for anti-HBc before vaccination remains crucial.

Female↗
PubMed2006

Variance of surgeons versus pathologists in staging of colorectal cancer.

AIM: Accurate staging of colorectal cancer depends on adequate retrieval and reporting of lymph nodes in the specimen. The presence of positive lymph nodes is an indication for adjuvant therapy. Both surgeons and pathologists influence the number of lymph nodes that are retrieved and reported in specimens. Although several recommendations exist in the literature regarding the minimum number of lymph nodes required for reliable staging, the relationship of examined to infiltrated lymph nodes has not been clarified. The aims of this study were to examine variance among surgeons and pathologists in the retrieval and reporting of lymph nodes in colorectal cancer specimens; to examine the relationship between retrieved/examined lymph nodes and infiltrated lymph nodes; to identify in our own series the minimum number of retrieved lymph nodes required to secure accurate staging. METHODS: Cross-sectional study of 284 patients with colorectal cancer followed in our hospital and retrospective analysis of histopathology reports. Correlation analysis, ANOVA, and survival analysis were performed on the data. RESULTS: There were 127 patients with cancer of the rectum and 157 patients with cancer of the colon under follow-up. The median number of lymph nodes per specimen was 8 (range 0-29). There was no difference in the number of retrieved lymph nodes among 9 surgeons. There were 2 outliers among pathologists, with one reporting a mean of 11.4 (9.8-12.9) 95% CI nodes per specimen and another reporting a mean 4.9 (3.6-6.2) 95% CI nodes per specimen. Dukes and T stage did not affect the number of nodes. Correlation analysis revealed a linear correlation between the total number of reported lymph nodes and the existence of positive lymph nodes. From the correlation equation we calculated that, in order to have one positive node, a minimum of 8.4 nodes was required in the specimen. Therefore, in our group of patients, a minimum of 8.4 nodes was required for accurate Dukes staging. However, survival analysis did not show any difference between patients with more and patients with less than 9 reported lymph nodes. CONCLUSIONS: Variance among pathologists exists and may be at least as important as variance among surgeons. Specialisation of pathologists similar to that of surgeons as well as employment of new techniques may be required . There is a linear correlation between the number of examined lymph nodes and the presence of positive nodes in a colorectal cancer specimen. This linear correlation makes the calculation of the minimum number of lymph nodes possible. In our series a minimum of nine nodes must be examined. However, we have not demonstrated an effect of inadequate nodes numbers on survival, possibly because survival in colorectal cancer is multifactorial.

Analysis of Variance↗
PubMed1991

Education and credentialing of the gynecologic laser surgeon.

Gynecologic laser surgery involves the use and understanding of a number of different wavelengths (lasers) and their delivery systems. The educated laser surgeon understands the pros and cons of all the practical wavelengths, their tissue reactions, and their safety features. The laser surgeon may use a colposcope, hysteroscope, laparoscope, or laser handpiece in surgery. Few gynecologists have acquired the necessary expertise to perform laser surgery during residency training. For this reason, attendance at courses that include hands-on laboratory experience has been mandatory. Hospitals, not course directors, credential surgeons to perform laser operations in their operating rooms. The credentialing committee of the hospital must decide which surgeons have been properly trained for laser surgery. Objective criteria have been offered in this chapter in the effort to make the task easier and more fair. As the number of laser surgeons grows, the need for training courses may decrease, because if laser surgery is learned during the residency years, the demand for postgraduate training will decrease. On the other hand, since surgical laser evolution continues, the training center will continue to offer a valuable educational experience.

Credentialing↗
PubMed1990

Samuel D. Gross: pioneer academic trauma surgeon of 19th century America.

It is appropriate on the 50th anniversary of the American Association for the Surgery of Trauma to recall the most influential trauma surgeon in 19th century America: Samuel D. Gross. Gross was an innovative surgeon whose 50-year career as a surgeon caring for injured patients encompassed orthopedics, thoracic surgery, abdominal surgery, and ophthalmology. The dominant influence of Gross over contemporary surgical doctrine was a consequence of his prolific scholarship which included six superbly written texts that passed through a combined total of 15 editions. Gross was a teacher, occupying for 42 years Chairs of Surgery at three medical schools. Gross wore the mantle of political leadership, founding medical societies that continue today as forums for the presentation and review of new treatments for injured patients. Modern academic trauma surgeons could do no better than to emulate the career of Samuel David Gross, the Patriarch of American trauma surgeons.

General Surgery↗
PubMed1987

The relationship between surgeon experience and endometritis after cesarean section.

We studied 294 primary cesarean section and repeat cesarean section deliveries with premature rupture of membranes which occurred over a two year period to determine if an association existed between postoperative endometritis and the level of physician training. The results of preliminary analysis revealed that a relationship existed between the level of physician training and the presence of endometritis (p less than 0.01). Endometritis rates for patients under the care of attending physicians, chief residents and residents serving as the primary surgeon were six, 13 and 24 per cent, respectively. Stepwise discriminant function analysis allowed us to account for the contribution of independent risk factors for endometritis. When surgeon experience was evaluated with other risk factors, the presence of a resident serving as the lead surgeon and the age of the patient were the only significant predictors of endometritis (p = 0.046 and 0.007, respectively). The clinical and biologic relevance of the actual age difference between infected and noninfected patients (22 years for infected patients versus 25 years for noninfected patients) is not readily apparent. However, in this study, the identification of a resident acting as a lead surgeon has been shown to be a new independent risk factor for predicting endometritis. This study demonstrates the need for the evaluation of training programs for residents who serve as the principal surgeon for patients who underwent cesarean section.

Adult↗
PubMed1986

Symposium on surgical manpower in the smaller community. The Canadian Association of General Surgeons' questionnaire: results and observations.

The Canadian Association of General Surgeons distributed a questionnaire to members located in communities of 40 000 population or less. The objective was to establish a minimal referral base of general surgeons, to identify the scope of procedures performed and the adequacy of training for serving smaller communities and to gain knowledge of the need for other specialists and the activity of the general practitioner-surgeons in smaller centres. A review of 92 replies indicated that, in general, these surgeons are very satisfied with the hospital and laboratory facilities, and perform a broad range of operative procedures for which there is abundant operating time. In communities of 10 000 to 20 000 there appears to be a need for extra training in obstetric, gynecologic and orthopedic procedures. Most of the larger communities have an adequate number of other surgical specialists with the exception of neurosurgeons. Of the respondents, 80% practised on a referral basis only with an average of 10 referring general practitioners; 24% were in competition with general practitioner-surgeons, but most indicated that this is a diminishing problem. It appears that practice in small communities provides a very rewarding and professionally challenging surgical career.

Canada↗
PubMed1979

[Federation of Swiss Physicians and the training of general surgeons].

The author recommends the Residency Program of the Halsted type as developed by D.C. SABISTON in the Departement of Surgery at Duke University. A two-year training in the basic problems, knowledge, and attitudes, common to all surgical subspecialties, is of fundamental importance (Fig. 1). The goal of this type of training is the US-Board Certification.--The Swiss Medical Federation considers the following factors as essential in a surgical training programm: The training of the general surgeon should be geared to broad principles without early overspecialisation. The training should allow a certain flexibility for the teacher as well as the candidate. A sufficient operative experience is paramount as well as the habit of a continuous education all trough a life-long surgical career and an understanding for economy in surgical practice.--The training of an university--or a private--surgeon does not give rise to important problems, whereas the training of surgeons for the medium sized and small Swiss hospitals represents a difficult problem. A double training in "visceral" and "orthopaedic" surgery with an accent on one or the other seems necessary in order to have one chief surgeon take the place of another during vacation, week-ends and illness. Even if such a complete training seems desirable, it can be justly questioned if under the present circumstances (emergency transportation, regionalized hospital organization, specialized hospital consultants) it is still justified to aim at the training of a "complete" surgeon who elsewhere, in a university hospital or in private practice or for that matter in other countries, is no longer absolutely necessary.

Certification↗
PubMed1983

[Pierre Fauchard (1677?-1761). Dental expert and master surgeon of Saint-Côme of Paris].

Pierre Fauchard has raised enigmas namely as regards his professional life which we try to elucidate by the analysis of his book. He began his dental training with a naval surgeon who did not sail anymore and he started practicing at the age of 19 with some dangerous interventions in the mouth of a friend. He benefited from the imbroglio of his time when the dental practice was not much supervised. In 1699 there was a compulsory examination to receive the title of 'Dental expert' which Fauchard obtained around 1708 in Paris. A short time afterwards it appeared that he undertook studies to become a Master-Surgeon, which title he obtained around 1714-1717, if one follows the 'Observations' in his book. As a matter of fact he operated already before 1715 with the great master-surgeons of his time, which would have been paradoxical if he had been only an Expert whose surgical operations described were not allowed by the strict regulations of the College Saint-Côme. His position as master-surgeon is revealed in the 1758 register of this company. The title-page of his book indicates it too by its presentation, as one reads 'by Pierre Fauchard surgeon' and at the next line: 'dentist in Paris'. The present paper intends to show that P. Fauchard was a practitioner with serious and long medical and surgical studies behind him.

Dentistry, Operative↗
PubMed1993

Women in surgery in Scotland. A Working Party of the Royal College of Surgeons of Edinburgh.

Despite the fact that 50% of medical undergraduates are female, women comprise fewer than 1% of consultant general surgeons. The possible reasons for this were addressed by a working party of the Royal College of Surgeons of Edinburgh, which now reports the results of a survey of 35 women surgeons of SHO 3 grade and above working in Scotland. Findings were compared with those of 12 anaesthetists and 10 house officers. Surgeons had had an accurate perception of the work patterns their job would entail but no preparation for the lifestyle implications. The experience of gender discrimination was similar in all three groups but perceived discrimination was much more prevalent among surgeons/ophthalmologists. In contrast to the other groups surveyed, the surgical cohort was not deterred by training length, but rather discouraged by the lack of responsibility offered. Other factors which seem to contribute to the underrepresentation of women among surgeons may be the lack (1) of time for child rearing and (2) of same-sex role models.

Adult↗