International College of Surgeons - United States Section

79th Annual Surgical Update

Airport Marriott Hotel – Seattle, Washington

June 15-17, 2017


Abstracts and Presentation Descriptions


Adnexal Torsion in the Pediatric Age Group : A Rare but True Clinical Entity

Domingo Alvear, MD, FICS, Chief, Division of Pediatric Surgery Pinnacle Health System, Mechanicsburg, PA


Adnexal torsion,although rare,is the most frequent gynecological emergency in children. Sudden severe unrelenting lower abdominal pain is the usual presenting symptom. The majority of adnexal torsion occurs without any ovarian or parovarian pathology.


17 patients age 2 to 15 years were seen with this condition in the last ten years. 90% of the patients had no prior symptoms. One patient had a prenatal mass and presented at age 2 years with acute pain. 3 patients age 6 to 8 years had some activities that precipitated the torsion. Cart wheeling, somersaults, swirling motions can precipitate torsion. Sequential torsion can occur several years apart. Doppler ultrasonography is the mainstay for diagnosis.


Immediate surgical intervention is the treatment of choice to preserve the adnexa and the ovary. Resection is employed only if necrosis of the ovary is definitively noted after observation. In the presence of a dermoid cyst,local resection with preservation of the remaining ovary can be done.

Conclusion: Adnexal torsion should be suspected in girls with severe unrelenting lower abdominal pain. Doppler ultrasound will confirm the diagnosis. Surgery with preservation of the ovary is the goal.


The Value of Surgical Missions to Third World Countries is a Surgical Training Program

Domingo Alvear, MD, FICS, Chief, Division of Pediatric Surgery Pinnacle Health System, Mechanicsburg, PA


Surgical missions to low income countries in the world can be advantageous to a surgical resident in training if he or she is working with attending surgeon who can teach surgical procedures performed without sophisticated equipments and in an environment that requires good basic knowledge of surgical principles. In an era where majority of surgical procedures in the USA is performed laparoscopically or robotically,conversion to open surgery becomes a challenge to the trainee. Majority of surgery performed during these missions is done by open technique. The trainee will be exposed to all kinds of surgical procedures for major and minor cases.


Since 1997,surgical missions had been conducted in 8 countries. Over 7,500 procedures have been performed which include thyroidectomies for goiters, cholecystectomies, herniorapphies, hydrocelectomies, plastic surgical procedures and gynecological procedures. Pediatric surgery includes pull through for Hirschsprung's disease and Imperforate Anus. Surgical surprises are extremely rare cases not usually seen during training.


The surgical resident can benefit both clinically and technically. He or she can learn innovative and efficient methods of managing problems without the use of expensive or sophisticated equipment. The resident can grow morally by taking part in the care of patients who would not otherwise receive basic surgical care without financial or legal restraints


Mammary Analogue Secretory Carcinoma of the Parotid Gland - A Relatively New and Rare Salivary Gland Tumour.

Asiri Arachchi, MBBS, General Surgical Doctor Monash Health Network, Melbourne, Victoria, Australia


Approach to Parotid Lesions particularly when they are of rare significance

Aim at investigation of such Lesions and other differential diagnosis

In setting of rarity and application of histopathology aims of management

Given our experience we discuss investigation, differential diagnosis, radiological investigation, histopathological discussion and management recommendiations.


This is a extremely rare tumor and we have analysed appropriate literature and discussion of its case is important particularly amongst the surgical, pathology health care community


Long-Term Outcomes of Geriatric Trauma Patients

Sam Arbabi, MD, MPH, FACS, Professor of Surgery, University of Washington, Seattle, WA


There is a significant increase in the number of older trauma patients. In addition to management of traumatic issues, the medical team requires to treat the premorbid conditions and be aware of the patient's frailty status. Care of older trauma patients will not end at the conclusion of their acute care stay and post hospital rehabilitation is equally important. This presentation will discuss acute hospital and post hospital care of older trauma patients.


Transanal Approaches for Surgical Management of Rectal Cancer

Greta V. Bernier, MD,  Acting Assistant Professor, Department of Surgery, University of Washington, Seattle, WA


The management of rectal cancer continues to evolve with emphasis on organ and sphincter preservation and improvements in high quality minimally invasive oncologic surgical approaches. Endoscopically unresectable benign rectal polyps as well as low grade rectal cancers, which were previously treated with proctectomy, can now safely be treated with transanal local excision in the appropriate patients. For our patients with more advanced cancer requiring proctectomy as part of their multidisciplinary care, total mesorectal exicision is the gold standard. This is challenging in an increasingly overweight population and in patient's with narrow pelvises. To counteract these difficulties some surgeons are using our transanal minimally invasive surgical techniques to perform the TME transanally (taTME). These new techniques are affording patients more options in the surgical care of their rectal masses and affording surgeons a new approach to the pelvis. This information is important as we council patients on their options and, in particular, the ability to have organ or sphincter preservation when it was previously not possible. After the presentation the learner will be able to understand transanal approaches to local excision of benign and low grade rectal cancers as well as transanal minimally invasive surgical approaches (TAMIS) to the total mesorectal excision (taTME). The audience will benefit from this presentation in their understanding of new innovations in rectal tumor surgery and how it benefits our patients.


Esophageal Stents: a Single-Center Retrospective Review of Surgical Experience

Tessa Cartwright, MD, MPH, FICS, Cardiothoracic Fellow, University of Kentucky, Lexington, KY


Purpose: Esophageal stents have been utilized in benign and malignant processes for the past 20 years.  Despite earlier diagnosis, improved multimodality treatment, and improved operative technique, the 5-year survival for esophageal cancer remains at 20%.  Given the grim prognosis, esophageal stents have been used over the last 20 years for palliation.  Known complications of esophageal stents are aspiration, malposition, dislodgement, perforation, bleeding, fistula formation, and migration.  In previously published data, complications related to stent placement for malignancies range from 30-50%.  Additionally, stents have been increasingly used in the treatment of benign esophageal diseases such as strictures, perforation, leaks, and fistula formation.  There is a wide range of success rate in the literature for stents placed for benign disease (17-95%).


Methods: We undertook a retrospective analysis of the electronic medical records from University of Kentucky Cardiothoracic Surgery Division to evaluate the experience of esophageal stent placements using codes 43219 and 43212 between January 2000 to December 2014.   A review of the literature was also performed.   Data was analyzed using SPSS statistical software v. 23 (IBM Corp., Armonk, NY).

Results: Of the one hundred procedures identified, two pediatric patients receiving 11 stent procedures for TEF were excluded, leaving 89 procedures performed in 54 patients for analysis. Twenty-three patients had two or more consecutive procedures. The median age at time of procedure was 59 years (range 20-85) and two-thirds of procedures were performed in males (59/89). Two-thirds of procedures were performed in patients with a history of esophageal or lung cancer. Indications for surgery included dysphagia (n=25), perforation (n=23), fistula (n=19), stricture (n=15) and leak (n=7). Stents included 20 proximal, 21 middle and 48 distal esophagus placements.


Morbidities included 24 stent migrations, 2 displacements, 2 obstructions, 8 esophageal leaks, 4 fistulas, and one each of pneumonia, airway compression, dysphagia, and hemoptysis. The morbidity rate for benign indication was 64.5% versus 41.4% for malignant indication (p = .047). 


Of the 54 patients, 12 were lost to follow-up such that their mortality status is unknown. In the remaining 42 patients 30 (71%) died at a median 107 days (range 2-2383) after their first or only stent placement. Mortality was 72% (26/29) in malignant indications vs. 22% (4/13) for benign indications (p = .001).  30-day death only occurred in the malignant group (7/29, 24%).


Conclusions: Esophageal Stents are commonly used for palliation and for contained leaks.  Perioperative mortality is low for benign indications; however, the morbidity rate was significantly higher for those with benign indications as compared to malignant. The overall mortality was significantly higher for malignant indications as compared to benign. For malignant indications, patients receiving adjuvant chemotherapy or radiotherapy, in addition to stenting, survived significantly longer than those with a stent only.


Use of Ultrasound for Management of  MusculoSkeletal Pathology

Naga Suresh Cheppalli, MD, FICS, Adjunct Assistant Professor PNWU, Clinical Perceptor Heritage University, Richland, WA


In Musculo Skeletal Injuries- after X rays MRI are most commonly used diagnostic modalities. MRI is quite expensive and sometimes it is invasive with its own complications and restrictions. It is not real time and time consuming can be a daunting experience. Ultrasound is very underutilized tool in MSK injuries, Mostly because of lack of training during orthopedic or sports medicine training. It is easy to use and learn with quite steep learning curve. I would like to use this platform to emphasize the ease and portability of USG and technique of ultrasound


Return to Play After Combined Ligament Knee Injury

Naga Suresh Cheppalli, MD, FICS, Adjunct Assistant Professor PNWU, Clinical Perceptor Heritage University, Richland, WA


Background: For this study purpose we defined Combined Ligamentous Knee Injury (CLKI) as having  two or more major ligament injuries among four major ligaments in the knee. CLKI is not uncommon injury,  yet return to play (RTP)  after CLKI ( two or more  ligaments of knee )  is not well known.


Purpose: To determine actual rate to RTP after CLKI and identifying  factors causing them not to reach this status.


Study design: Case series; Level  4


Methods:  Inclusion criteria for this study is   1. Players operated by senior author LL (attempt to reduce more number of variables) 2.Active athletes at a competitive level (High school, Collegiate, Professional) and injury occurred on the field while playing (did not include recreational athletes or CLKI secondary to motor vehicle accidents (MVA) or falls ) 3. At least injured two major ligaments in the knee and unstable in two planes at the time examination under anesthesia 4. Minimum of one year follow up


31 athletes who fits into this criteria were identified(Jan05-12). All the patients underwent at least one ligament reconstruction/repair. Players demographics and injury mechanism and level of play and injury details were collected prospectively with ASMI(American sports medicine Institute) data sheet. Chart reviews were performed to document immediate post op complications.  For the final follow up a self report questionnaire was used to collect data at  minimum of one year follow up regarding pre injury level of play and post injury return to play, Lysholm score, Knee injury Osteoarthritis outcome score (KOOS) , Satisfaction rate after the surgery using Likert scale.


Results: A total of 31 number of patients were identified who were operated by senior author (LL) from 2005-11. We excluded two patients from the study as they did not meet our inclusion criteria. Among 29 patients we could able to contact only 19 players over telephone and chart review for these patients have been performed. Mean age of players is 18.7 yrs. At average follow up of 53 months 15 players (78.9%) have returned to their pre injury level of sports. Among four players (21%) who could not able to return to play two players (10.5%) could not return to play because of knee pain and two could not play because they are worried about further injuries during games. Mean Lysholm score is 83.1 and Knee injury and Osteoarthritis Outcome Score (KOOS) is 88.7. Everybody felt the surgery has helped them on Likert Scale. The average time to return to play with maximum potential very  much comparable to their pre injury status  is approximately 12 months.


Conclusions: Combined Ligamentous Knee Injury is not uncommon and difficult to manage. However with appropriate management strategy good percentage (79%) of patients can still return to play to their pre injury level. Approximately it took  12 months for players to return to play with maximum potential. If the injury pattern involved both ACL and MCL, 100% of players returned to play. If injury pattern also involved PCL only 50% of patients returned to play. If injury pattern involved PCL and was not reconstructed 100% of patients could not return to play.


Robotic Training for the Future Surgeon: Approaches to Education of Surgical Residents in the U.S.

Kenneth Henry Copperwheat, DO, FICS, Surgical Resident, Presence Health St. Joseph Hospital, Chicago, IL


Robotic surgery has provided an alternative to the well-established open and laparoscopic approaches in parallel fields. There are 257 general surgery training programs and over 4500 general surgery residents in the United States. All 257 programs have set curriculums and certifications for training of surgical residents in laparoscopic surgery including mandatory certification in Fundamental of Laparoscopic Surgery (FLS) before completion of training. Of those 257 however, less than 20 have set curriculums and training programs for robotic surgery.  There is currently limited published literature on the training of surgical residents in robotic approaches and no official requirements or certification programs for trainees. Individualized institutional approaches to robotic training, such as those used at our institution and large academic centers such as University of Alabama, along with use of resources available from the industry will lead to better resident education and training. This will set the groundwork for more structured training and certification programs in the field of robotic surgery.


Our experience with robotic inguinal hernia repairs in a community hospital training program has been largely positive. Residents are required to complete training modules on the robotic trainer addition box and record their scores accordingly. Once completed, residents are allowed to operate the robot on the live patient. Despite the learning curve, chief residents are capable of making the transition rather quickly and perform the entire operation with guidance from the attendings.


Aortoiliac Transection following Blunt Abdominal Trauma in a Child

Edward Daniele, MD, Surgical Resident, Texas Tech University Health Sciences Center, Lubbock, TX


Background: Although trauma and unintentional injury is the primary cause of mortality in children from ages one to twenty one, pediatric vascular and aortic injuries are extremely rare.  The most common mechanism of aortic injury reported is motor vehicle collisions with aortic disruptions occurring almost exclusively in the chest (95-99%) (1,2).   Abdominal aortic injury following blunt trauma is almost twenty times less likely than the thoracic aorta, making its repair even that more challenging.  


Objective: Since the incidence is so low, there are few reports regarding pediatric abdominal aortic injury following blunt trauma.  The clinical presentation and repair of the aorta varies depending upon the mechanism, ranging from ATV accidents to soccer injuries


Methods: Patient is a 7 year old boy who was involved in a motor vehicle accident, head on collision, at high speed. The patient was the rear passenger and was restrained with just a lap seat belt.  On scene, he was hemodynamically stable, with a GCS of 15.  He presented to the nearby hospital first where he was worked up with a cat scan.  He was transferred to our hospital three and a half hours after the incident.  On arrival he complained of abdominal pain.  His CT scan from the outside hospital showed pneumoperitoneum, a distal aortic tear, and a chance fracture of the L3 vertebra.  A left sided distal aortic transaction was found upon entrance of the retroperitoneum and evaluation of the aorta.  After opening the aorta, a complete transection of the intimal layer for about 2cm was observed.

Results: A rectangular strip of bovine pericardium was placed at the base of the defect, reconstituting the proximal iliac and distal aorta at the bifurcation.  Adventitia and intima of the vessel was approximated over the bovine pericardium bridge. Once the vascular portion of the case was completed the neurosurgery team performed a posterior spinal fusion for his L3 chance fracture.  Following the procedure the patient had palpable distal pulses. 


Discussion: Pediatric aortic trauma is a complicated and challenging repair due to the prospective growth of the child over time.  Primary repair of thoracic aortic injury has been thoroughly described in the literature with successful results (7).  For abdominal aortic injuries, particularly zone III, different approaches have been taken including open repair, endovascular repair, or a multimodal approach.  In the setting of gross contamination or polytrauma, newer endovascular repair appear to be a more attractive option, especially for pseudoaneurysms, while other literature suggests maintaining an open approach. Even though primary repair of aortic transections have shown positive long term results, there are instances where the anatomy of the injury does not lend itself to this type of repair (such as the aortoiliac bifurcation as presented in our case).  Interposition grafts could leave a child with a fixed diameter aortic segment, contributing to the development of pseudocoarction. Keeping this in mind is of great importance during reconstruction.


3d Printing in Chest Wall Pathologies

Marcelo DaSilva, MD, FACS, FCCP, FICS, Harvard Medical School, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA


Pectus excavatum is the most common congenital sternal deformity 1 in 400 children. The incidence in the adult population is not known, therefore repair of pectus excavatum and chest wall defects require a different approach. 3D reconstruction has been to help with planning of new technique for repair of Pectus Excavatum in adults with excellent cosmetic and anatomical results.


Neuroprosthetic Platform for Cough and Respirations

Raymond A. Dieter, Jr., MD, FICS, General and Thoracic Surgeon, Glen Ellyn, IL


Introduction: Our group has been involved in research on paraplegia and quadriplegia due to spinal cord injury. Respiration and cough are significant concerns in these injured individuals - approximately 180,000 each year in the United States. Various programs are under investigation to enhance respiration and cough and reduce respiratory and intubation concerns.


Project: Utilizing adult canine animals weighing 27.0 +/- 0.7 kgm under propofol and sevoflurane general anesthesia, instrumentation was carried out to monitor, heart rate, EKG, abdominal and thoracic pressure, and respiratory volume and flow. Optimization of surface electrode stimulation was studied for abdominal and upper thoracic musculature while utilizing a 12 - channel neuroprosthetic computerized platform and measuring the inspiratory and expiratory volumes.


Results: Optimized abdominal studies included 80 - 100 m Amp current applied via three or four sets of bilateral electrodes placed dorsal to the lateral abdominal line at the 8th to 13th interspace, the expired volumes measured 358 +/- 31 ml. Optimal upper thorax stimulation included 60 - 80 mAmps and single sets of bilateral electrodes placed at the second interspace induced a 304 +/- 54 mil inspired volume.


Summary: Surface electrode stimulation of abdominal and upper thoracic musculature provided adequate respiratory volumes for cough and ventilation. Such techniques may prove effective in maintaining respiration and avoiding long term tracheostomy in individuals with spinal cord injury.


Umbilical Hernia Repair in a Remote Surgery Center

Raymond A. Dieter, Jr., MD, FICS, General and Thoracic Surgeon, Glen Ellyn, IL


Introduction: Hernias are common occurrences, especially in the male. Umbilical hernias are a frequent finding in patients complaining of a lump or discomfort in the midabdominal wall.


Project: A ten year review of the patients with diagnostic and therapeutic CPT provider codes for umbilical hernia (repair at a remote non hospital surgicenter) was tabulated. The surgeon, anesthetic, suture type, use of mesh and pathology were reviewed and summarized along with the type of surgery.


Results: Multiple surgeons used multiple surgical techniques for umbilical hernia repair. These techniques included primary suture with absorbable and non absorbable suture, simple approximation or vest over pants, closure mesh patch or plug use or not, local or general anesthesia. Absorbable mesh or permanent mesh, reduction of incarceration or resection, and incision location above, below or in the umbilicus were all utilized. No patients were readmitted with complications.


Summary: Repair of small to medium sized (up to 6 - 7 cm) umbilical hernias, whether incarcerated or not, may be repaired safely in remote non hospital surgical facilities with the concomitant economy and facility ease of transportation for the patient and family.


Introduction and Capacity Building of Neonatal Resuscitation Program of American Academy of Paediatrics in Pakistan

Maqsood Elahi, MD, PhD, FICS, Professor of Cardiovascular Sciences, Department of Cardiothoracic Surgery, Heart & Lung Research Institute; Director CardiacEye International Foundation, Irving, TX


Pakistan has the third highest neonatal mortality rate in the world.  Prematurity, birth asphyxia and neonatal sepsis are the leading causes of neonatal death and are closely linked to obstetric factors.


The NRP (Neonatal Resuscitation Program)Provider Course of AAP (American Academy of Paediatrics) introduces the concepts and a basic skill of neonatal resuscitation. We aim to introduce and build capacity in neonatal resuscitation in Pakistan according to AAP guidelines.


NRP, 6th Edition was introduced for the first time in Pakistan through a partnership between the Institute of Learning Emergency Medicine, University Of Health Sciences (ILEM, UHS) Lahore and NRP instructor certified in Ireland.


NRP 6th Edition text book was provided to all the participants, followed by course for skills training, simulation, debriefing and written exam with passing score of 80% as per AAP guidelines.


Candidates who attended hands on training and passed the written exam were deemed certified.  Limitations in internet access prohibited the use of an online exam. 


Results: A total of 17 courses were held, with 201 participants being taught (1 course with 13 participants in 2014; 8 courses with 72 participants in 2015 and 8 courses with 116 participants in 2016). Participants were predominantly female [126 (62.6%)] and predominantly doctors [141 (70.14%)].  Allied health professionals accounted for 30% of participants [nurses 55 (27.3%), paramedics 4 (1.94%), others 1 (0.49 %)]. To date, 97 (48.2%) participants have completed the written exam. Of these, 83 (85.5%) passed with the remaining 14 (14.4%) needing remediation. 104 (51.7%) did not attend for the written exam.


Compliance with written examination was low however results show a high pass rate in those who attended both aspects of NRP training. Simulation training followed by a written exam can effectively improve technical skills and teamwork in neonatal resuscitation and is the first step to improving neonatal morbidity.


Laparoscopic Remnant Cholecystectomy After 52 Years of Open Cholecystectomy

Mohanad Elshiekh, MD, Surgical Resident, Texas Tech Health Science center, Lubbock, TX


Background: Cholecystectomy is the standard treatment of symptomatic cholelithiasis. Recurrence of biliary symptoms following cholecystectomy, either open or laparoscopic technique is a diagnostic and therapeutic dilemma, Causes are either biliary or extra-biliary. Symptoms of biliary origin usually due to retained bile duct stones or strictures. Rarely, they caused by stone recurrence or inflammation in a gallbladder remnant. Diagnosis and management of acute cholecystitis or cholelithiasis in gallbladder remnant is difficult.


Objective: To report a case of symptomatic cholelithiasis in a gallbladder remnant, presented 52 years following open cholecystectomy and successfully treated by laparoscopic completion cholecystectomy, proving that the laparoscopic approach is feasible and safe.


Method: 52 years after cholecystectomy, a 75-year-old woman represented with right upper quadrant abdominal pain, nausea, vomiting followed by fever, there was no history of alcohol or drug ingestion. On examination there was right well healed subcostal Khocher scar, localized  right upper quadrant and epigastrium tenderness, A diagnosis of choledocolithiasis and symptomatic cholelithiasis was made after abdominal ultrasound identified a fluid filled pouch with stones and sludge, magnatic resonance imaging (MRI) confirm remnant gallblader, dilated common bile duct (CBD) with stones , and endoscopic retrograde cholangiopancreaticography (ERCP) confirmed a diagnosis of biliary obstruction , sphicterotomy performed with passage of stones and pus. The patient then subsequently underwent laparoscopic completion of cholecystectomy and intraoperative cholangigram to identify the cystic duct. Preoperative attempt was made to obtain previous medical records, but were not able to obtain them, because the hospital was closed and the surgeon was deceased.


Result: Patient underwent uneventful laparoscopic completion of cholecystectomy and intra-operative cholangiogram, Pending pathology report.


Conclusion: Patients underwent partial cholecystectomy are at risk of symptomatic gallbladder remnants, once diagnosed patient should subjected to completion cholecystectomy via open or laparoscopic technique .We advocate for laparoscopic technique , however advanced laparoscopic training is required and a routine  intraoperative cholangiography should be performed.


Update on the Treatment of Colorectal Cancer

Alessandro Fichera, MD, Professor and Section Chief Gastrointestinal Surgery Division of General Surgery, University of Washington Medical Center, Seattle, WA


Management of colon and rectal cancer has significantly evolved over the past decade. While surgery remains the main curative modality and the quality of surgery (i.e. total mesorectal and total mesocolic excision) dictate the long-term prognosis both medical and radiation oncology play a major role in the multidisciplinary management of these diseases. In this presentation we will review the most recent advances in the medical and surgical management of curable colorectal cancer.


The audience should be aware of the different options available nowadays to the point of defining the treatment of colorectal cancer almost individualized to the single patient. Timing of surgery in relation to the other treatment modalities is critical and understanding the principles of management nowadays requires a significant level of expertise.


After the presentation the learner should be able to properly refer colon and rectal cancer patients to centers where multidisciplinary management is available. The days of exploratory surgery are long gone. With modern imaging modalities, accurate staging pretreatment and post treatment - pre surgery is available to properly guide the surgical approach.


The audience will be able to appreciate the value of quality surgery and specialization, especially when treating rectal cancer where meticulous quality surgery does make the difference between a good outcome and catastrophic consequences.


Robotic Lobectomy for Lung Cancer: The Moffitt Cancer Center Experience

Jacques Fontaine, MD, FICS, Moffitt Cancer Center, Associate Professor, University of South Florida, Tampa, FL


Objectives: Minimally invasive pulmonary lobectomy has now become the standard of care for early-stage lung cancer.  The use of robotic technology as a minimally invasive technique is rapidly increasing.  The goal of this study is to review our cancer center's experience with the first 500 consecutive lobectomies in terms of patient safety, operative outcomes and oncologic results.  

Methods: We performed a retrospective chart review of prospectively collected data from the first 500 consecutive robotic lobectomies performed at a single institution by two surgeons from 2011 to 2016. We reviewed patient characteristics, operative data, post-operative outcomes and survival curves. 


Results: Between 2011 and 2016, 500 patients (median age 68 years old) underwent a robotic lobectomy. The majority of patients had Stage I adenocarcinoma. For the entire cohort, median operative time was 165 minutes (range 75 to 240 minutes) with a short learning curve. Only 15 patients required conversion to thoracotomy – most often to control bleeding.  Median chest tube duration was 3 days and median hospital stay was 3 days. Complications occurred in 104 patients with atrial fibrillation accounting for over half of them.  There was no perioperative mortality. Oncologic survival was similar to survival curves from previously published series of thoracoscopic (VATS) lobectomies.


Conclusions: Robotic-assisted surgery is a safe technique for patients undergoing minimally invasive pulmonary lobectomy.  Operative times, peri-operative complication rates and oncologic outcomes are similar to previously published video-assisted thoracoscopic (VATS) lobectomy series.  However, as compared to VATS, the learning curve for this technology is faster and associated with a lower rate of conversion to thoracotomy.  In addition, there are several advantageous technological differences as compared to VATS which will very likely increase over time.


The Latest in Reconstructive Hand Surgery

Jeffrey Friedrich, MD, Associate Professor of Surgery and Orthopaedics, University of Washington, Seattle, WA, Seattle, WA


This presentation will review current standards of hand reconstruction including musculoskeletal, peripheral nerve and soft tissue considerations. New advances for these problems will be presented. Following the presentation, the audience members will be able to describe current hand reconstruction methods.


Successful Treatment in One Step Laparoscopic Procedure Using Same Ports Access for a Synchronous Presentation of Acute Cholecystitis and Acute Appendicitis

Federico Gattorno, MD, FICS, Attending Surgeon-Minimally Invasive Surgery, Department of Surgery, Woodhull Medical Center-NYU School of Medicine, Brooklyn, NY, Associated Professor in Surgery, St. Georges School of Medicine, Brooklyn, NY


Introduction: Acute appendicitis is one of the most common causes of the acute abdomen and one of the most common indications for an emergent abdominal surgical procedure worldwide. Around 10% of the adult population will have cholelithiasis, 1-4 % develops symptoms and 20% of those patients develop acute cholecystitis. Acute appendicitis and acute cholecystitis are among the most common pathologies seen on general surgery practice, however, they are seldom observed in a simultaneous or synchronous occurrence. Simultaneous appendicitis and cholecystitis in a single patient has only been rarely reported previously. Having awareness of the possibility of this double diagnosis will allow clinicians to entertain this differential in the patient with acute abdomen where the physical examination and the imaging present a mixed picture. We also aimed to describe the use of standard laparoscopic cholecystectomy port placements to achieve both cholecystectomy and appendectomy in a single setting.


Case presentation: A 41 year old man presented to the emergency department complaining of right upper abdominal pain of 10 days duration. This was associated with vomiting, fever and chills. On physical examination the abdomen was soft with mild tenderness on right upper and lower quadrants, there was no rebound tenderness or guarding present. Blood Laboratory analysis revealed no leukocytosis. Abdominal CT scan revealed a fluid filled dilated appendix with mural enhancement concerning for acute appendicitis, also  diffuse gallbladder wall edema was demonstrated as well on the CT scan with no biliary duct dilation but with periportal free fluid, this was confirmed with an abdomen ultrasound, concerning for possible acute cholecystitis. Patient underwent emergent laparoscopic cholecystectomy and appendectomy.


This was approached by umbilical Hasson port insertion, and three 5mm port insertion in the epigastric region and right midclavicular and anterior axillary subcostal spaces as for standard laparoscopic cholecystectomy. The gallbladder was visualized and was acutely inflamed with marked distention and edematous wall, appendix was also visualized and appeared dilated and hyperemic. After the gallbladder was removed, the appendectomy was performed using the same cholecystectomy ports, modifying instruments placement: the epigastric and midclavicular ports were used as working ports to remove the appendix. The surgery time was 1hr 20 min. Patient tolerated the procedure well with no complications and was discharged on postoperative day 3. Pathological evaluation of the appendix revealed changes consistent with acute appendicitis and gallbladder pathology showed acute cholecystitis superimposed on chronic cholecystitis with focal gangrenous change.


Conclusion: The possibility of a dual diagnosis of acute appendicitis and acute cholecystitis presented simultaneously bring it to the awareness of clinicians who frequently evaluate patients with acute abdomen. Also we describe for the first time in the literature simultaneous laparoscopic appendectomy and cholecystectomy through the same ports as used for standard cholecystectomy.


Just few simultaneous presentation of acute cholecystitis and acute appendicitis has been reported in the literature. This is an important information for the audience. The learner accomplish after this presentation is about how we could perform in one step a simultaneous laparoscopic cholecystectomy and appendectomy just modifying instruments rotation on standard lap chole ports placement. The audience will benefits lerning how to perform this technique.


Should We Attempt Early Withdrawal of Care or Expect Favorable Outcome in Patients with Severe Traumatic Brain Injury?

Shankar P. Gopinath, MD, FICS, Associate Professor, Neurosurgery, Baylor College of Medicine, Houston, TX


With increased focus on the decision and timing of withdrawal of care in patients with severe TBI, data on early neurological recovery in patients with a favorable outcome is needed to guide physicians and families. Prospectively collected data on 1241 patients with closed head injury from 1986-2012 were reviewed and selected patients with severe TBI, motor GCS (mGCS) score <6 on admission, and those who had favorable outcomes (GOS= moderate disability or good recovery) at 6 months. The time from injury to first record of following commands (mGCS=6) after injury was recorded.


We studied 218 patients (183 men, 35 women) with a mean age of 28.9±11.2 years. The majority of patients were able to follow commands (mGCS=6) within the first week after injury (71.4%), with most patients recovering on day 1 (28.6%). Recovery to following commands beyond 2 weeks from the injury was seen in 14.8% of patients, In comparison to patients with moderate disability, patients with good recovery had higher initial GCS score (p=0.01), lower incidence of anisocoria at admission (p=0.048), shorter ICU stay (p<0.001) and total hospital stay (p<0.001). There was considerable improvement in GOS scores from discharge to follow-up at 6 months. Up to 15% of patients with a favorable outcome after severe TBI may begin to follow commands beyond 2 weeks from the injury. These data caution against early withdrawal of life sustaining treatment in patients with severe TBI.

SW102 4

Complex Laparoscopic Liver Resection -Tips and Tricks

Michael Jacobs, MD, FICS, Clinical Professor of Surgery Michigan State University CHM, Birmingham, MI


The lecture will enable the learner to develop a more concrete understanding of the related anatomy, imaging assessment, and use of technology during laparoscopic liver resection.  A video-based education format will be used to demonstrate the technicalities of laparoscopic liver resection.


Will cover topics of additional tips and tricks that will facilitate the learners understanding of complex laparoscopic liver resection.


Central Pancreatectomy-How I do it

Michael Jacobs, MD, FICS, Clinical Professor of Surgery Michigan State University CHM, Birmingham, MI


Central pancreatectomy is an underutilized procedure for lesions of the pancreatic neck and body.  The author demonstrates through a video based format case presentations focused on the technical aspects of the procedure and the tips and tricks to ensure a good outcome.


Delayed Presentation of Traumatic Duodenal Perforation Leading to Early Empyema

Karla Leal, MD, Surgery Resident, Texas Tech University Health Sciences Center, Lubbock, TX


Background: Blunt traumatic injuries to the duodenum happen infrequently in trauma patients and they are usually the result of crushing or shearing forces. Anatomic location makes diagnosis of duodenal injuries challenging. Having a high index of suspicion for these types of injuries is imperative for early diagnosis and intervention.


Objective: Delay in diagnosis of duodenal injuries is associated with significant morbidity and mortality, with mortality rates reaching 40% when diagnosis is delayed beyond 24 hours. Early diagnosis of duodenal injuries requires a high index of suspicion. Blunt traumatic injuries are more difficult to diagnose than penetrating injuries. There is no single specific diagnostic test to consistently and accurately diagnose such injuries. The best assessment for duodenal injury should begin in the emergency room with a high index of suspicion based on mechanism of injury and associated traumatic injuries. Diagnosis of blunt traumatic injuries to the duodenum is near impossible without adjuncts like computed tomography or plain films demonstrating free intra abdominal air and even with such adjunct, in certain circumstances operative exploration is the only definitive diagnosis. Operative evaluation of duodenal injuries focuses on interrogation of entire duodenum, assessing for integrity, intramural clots and blood supply.


Methods: Patient is a 45-year-old male who presented after being involved in high-speed motor vehicle crash with ejection. Upon trauma evaluation patient was found to have sustained left sided rib fractures 3-9th with presence of pneumothorax/hemothorax, which was successfully treated with tube thoracostomy. Computed tomography obtained for preoperative planning revealed a gravity defined fluid collection in the left side of the chest. On hospital day number four, patient was taken to the operating room for left lateral thoracotomy for washout and rib platting. Intraoperative findings included a left lung with significant amount of rind along the previously identified displaced third through ninth rib fractures. After successful open reduction and internal fixation of ribs, patient was monitored in surgical intensive care unit. On postoperative day number two patient's morning chest radiograph depicted free intraabdominal air. Patient was asymptomatic at the time, with normal vital signs and normal laboratory studies. He was taken to the operating room for exploratory laparotomy to investigate pneumoperitoneum. Upon return to operating room, patient was found to have a posterior duodenal perforation measuring 2 cm by 1 cm as well as a 6 cm laceration to the left hemi-diaphragm.


Results: Patient underwent partial gastrectomy and duodenal resection, gastrojejunostomy anastomosis, gastrojejunostomy feeding tube placement and diaphragmatic laceration repair.


Conclusion: Diagnosis of blunt duodenal injuries is prone to delay due to its infrequent presentation. A high index of suspicion should be kept for patient's with unexplained symptomatology after initial resuscitation and stabilization. Duodenal perforations do not typically present with abdominal pain and frequently, diagnosis is not done until bacterial infections develop.


The early presentation of an empyema on the patient being discussed should have been a point of focus. This patient had an associated missed diaphragmatic injury, which facilitated extravasation of duodenal contents into the chest. Upon initial repair of rib fractures, even though the diaphragmatic injury was not addressed, pneumoperitoneum developed and it was not until specific radiographic abdominal changes established that this injury was diagnosed. In retrospect, the early development of an empyema (post injury day number three) should have been a clue of intraabdominal source of infection.


Protect What You Make: Best Practices in Asset Protection for ICS Members

David Mandell, JD, MBA, Attorney at Law; Consultant OJM Group, LLC; Author Guardian Publishing, LLC, Fort Lauderdale, FL


Surgical practices and surgeons themselves both face liability risk - for medical malpractice, but also as employers, holders of private health information, real estate owners, parents of teenage drivers, etc.  This presentation will explain common liability traps, including new HIPAA risks associated with technology; dispel common myths about asset protection and identify the Best Practices in the following areas: (1) using the proper entity or entities for the practice; (2) shielding practice assets from lawsuits, including real estate and equipment; (3) shielding cash flow and (4) protecting personal assets from lawsuits, including qualified plans, IRAs, the home, other real estate and liquid investments.


The New Science of the Brain and Chronic Knee Pain Leading to Total Knee Replacement

Robert Mathews, MD, PhD, FICS, Medical Director of First Team Institute, Millersville, PA


We sought the cause of pain.  I studied micro EM and Enzyme studies of 160 patients who underwent total knee replacement.  We found the cause of pain to be micro-fracture, inflammatory cell and histiocytes.  We identified peripheral nerve fibers in the knee joint, tendon, synovium and capsule.  We followed up with MRI of the brain plus other pain studies in patients with painful total knee replacements.  This followed studies of the brain, spinal cord, nerves and nerve endings.   Why does osteoarthritis lead to pain?  Why do some total knee patients hurt after surgery?


Surgical Fusion for the Treatment of Refractory Chronic Axial Low-back Pain in the setting of Advanced Degenerative Disc Disease:  The New Lumbar Fusion Outcome Score

Tobias Mattei, MD, FICS, Associate Neurosurgeon, Neurosurgery & Spine Specialists Eastern Maine Medical Center, Bangor, ME


In order to evaluate the predictive effect of non-invasive preoperative imaging methods on surgical outcomes of lumbar fusion for patients with degenerative disc disease (DDD) and refractory chronic axial low back pain (LBP), the authors conducted a retrospective review of 45 patients with DDD and refractory LBP submitted to anterior lumbar interbody fusion (ALIF) at a single center from 2007 to 2010. Surgical outcomes - as measured by Visual Analog Scale (VAS/back pain) and Oswestry Disability Index (ODI) - were evaluated pre-operatively and at 6 weeks, 3 months, 6 months, and 1 year post-operatively. Linear mixed-effects models were generated in order to identify possible preoperative imaging characteristics (including bone scan/99mTc scintigraphy increased endplate uptake, Modic endplate changes, and disc degeneration graded according to Pfirrmann classification) which may be predictive of long-term surgical outcomes . After controlling for confounders, a combined score, the Lumbar Fusion Outcome Score (LUFOS), was developed. The LUFOS grading system was able to stratify patients in two general groups (Non-surgical: LUFOS 0 and 1; Surgical: LUFOS 2 and 3) that presented significantly different surgical outcomes in terms of estimated marginal means of VAS/back pain (p?=?0.001) and ODI (p?=?0.006) beginning at 3 months and continuing up to 1 year of follow-up. In conclusion,  LUFOS has been devised as a new practical and surgically oriented grading system based on simple key parameters from non-invasive preoperative imaging exams (magnetic resonance imaging/MRI and bone scan/99mTc scintigraphy) which has been shown to be highly predictive of surgical outcomes of patients undergoing lumbar fusion for treatment for refractory chronic axial LBP.


As senior author of this research I intend to present a brief description of the study's methodology, results as well as how the conclusions of such study should guide the daily decision-making for spine surgeons when dealing with the challenging topic of refractory chronic axial low-back pain.


Surgical Treatment of Kyphotic Cervical Deformities: Therapeutic Algorithms, Pitfalls and Complications Avoidance

Tobias Mattei, MD, FICS, Associate Neurosurgeon, Neurosurgery & Spine Specialists Eastern Maine Medical Center, Bangor, ME


In this presentation I intend to discuss the available surgical options for treatment of cervical kyphotic deformities. Such discussion will be centered on the criteria which should be employed when deciding between the available therapeutic algorithms (such as the ‘back-front-‘back, isolated posterior approach, anterior approach with cervical traction + posterior approach, for example) as well as on intra and preoperative recommendations for complications avoidance. The discussion will be centered on a critical review of the available literature on the issue and will be illustrated with examples from my personal surgical casuistics.


New Technique: Minced Edge Transposition Graft (MET Graft)

Scott Moradian, DO, Surgical Resident, Larkin Community Hospital, Miami, Fl


Develop a tissue salvage technique to reconstruct acute wounds in patients with associated co-morbitities that allotted them high risk for the OR.  Additionally, such wounds upon presentation did not afford tissue for salvage.


11 acute full thickness wounds in series, treated at the Level 1 Trauma - varying in size and complexity (10 cm2 to 144 cm2). Patients aged 51 to 96 years old, each with complex medical histories allotting for high risk for general anesthesia .


-- 100% closure with epithelialization (2 of 11 patients developed hybrid wound healing of epithelialization with small areas of scab eschar between Skin Islands.) Note: For the purposes of this pilot study we consider scabbing a form of biologic closure.


The Role of Minimally Invasive Surgery in the Trauma Patient

Sharique Nazir, MD, FACS, FICS, Associate Professor, NYU Lutheran Medical Center, New York, NY


The role of laparoscopy has changed the face of surgery since it’s induction into the field. With research demonstrating superior outcomes of laparoscopy driven procedures even in more complex cases such as colectomies, it has quickly become a mainstay treatment modality of the general surgeon’s arsenal. As the laparoscopic revolution has taken off, the skill of the average general surgeon has spiked alongside new techniques, training methods, and overall clinical experience. The one area of surgery that still lacks considerable exploration has been the acute trauma patient.


Several studies from the 1990’s demonstrated a considerable amount of missed injuries from laparoscopy, later confirmed by laparotomy, that drew doubt on the efficacy of laparoscopic diagnosis . [9] This climate has changed immensely in the past decades as surgeon experience and technical skills have improved. With current technology, diagnostic laparoscopy has been shown to be a safe modality for hemodynamically stable abdominal trauma. [9] Not only has the incorporation of laparoscopy shown to decrease the rate of negative laparotomies, the advent of miniaturized clamps, retractors, and stapling devices have increased the breadth of therapeutic intervention. [12,2] In the pediatric population, Gustavo, et al demonstrated that these minimally invasive approaches have also had a major benefit in preventing unnecessary laparotomies as well as keeping hospital stays under two weeks. [8]

Traumatic abdominal injury has classically been approached with open exploration. With open exploration comes the challenges of operative and post-operative care, not limited to: wound infection, dehiscence, paralytic ileus, and often lengthy, expensive hospital stays. In 1997 a retrospective study by Zanut, et al demonstrated that out of 510 patients suffering penetrating wounds and GSW who were hemodynamically stable, integrating a laparoscopic approach in the workup allowed 277 patients to avoid a laparotomy. This study demonstrates the need for further implementation of laparoscopic minimally invasive techniques within the trauma algorithm.


MIS in trauma is generally only considered in patients who are hemodynamically stable, with instability as an absolute contraindication to MIS in trauma. Prior to 2000, only three published studies described experiences with laparoscopy as a therapeutic tool. Newer, contemporary research has started to challenge this notion. Cherkasov, et al demonstrated that video assisted laparoscopy surgery can confidently be used to evaluate and treat trauma regardless of hemodynamic stability. Kawahara, et al demonstrated that a standard systematic laparoscopic exploration was 100% effective at detecting small bowel injury in penetrating injuries. With studies demonstrating such promise, the issue still remains that many surgeons are unwilling to adopt an MIS approach to trauma. The skill set of the individual surgeon is still the most defining variable, but with continued participation in acute care surgery and further technological advances, MIS has the potential to be a highly therapeutic tool. More robust prospective studies are needed to further investigate the beneficial effects of therapeutic MIS in trauma. Further research is also needed to characterize the optimal indications and timing for MIS in trauma. Trauma surgeons should continue to actively participate in elective or acute surgery to maintain laparoscopic skills.


Early Experience Implementing an Enhanced Recovery Protocol in a Community Hospital Setting

Nancy Panko, MD, Surgical Resident, Presence Saint Joseph Hospital, Forest Park, IL


The common course of postoperative care in the cohort of patients undergoing colon and rectal surgery in the US and Europe is changing. As the benefits of optimizing pre and postoperative nutrition, early ambulation, avoidance of narcotics, and maintaining optimal fluid balance have been documented, the ‘Fast Track’ or ‘Enhanced Recovery’ era has emerged. We describe our early experience with implementing an Enhanced Recovery protocol for patients undergoing colon and rectal surgery in a community hospital setting.


A literature review was conducted using PubMed search for "Enhanced Recovery" and "Enhanced Recovery After Surgery." The search results were used to devise an enhanced recovery protocol suiting the practice model of the surgeons performing colorectal surgery at a 200-bed community hospital. The protocol was implemented by creating a standardized pre-operative, intraoperative, and post-operative care plan. Surgical residents, pre-op nursing, Anesthesiologists, PACU Nursing, and floor nursing staff were all educated on the protocol. Data were prospectively collected in Microsoft Excel for the first 10 patients undergoing colorectal procedures in the three-month period since implementation.


Of the 10 patients on whom data was available, nine had been using a preoperative nutritional supplement at least once a day for the five days preceding surgery. All 10 patients received intravenous acetaminophen and oral gabapentin prior to surgery start. Patients received an average of 6.4cc/kg/hr of fluid intraoperatively and just over half (n=6) still received some amount of opioids. There was one patient who suffered an intraoperative complication that would alter their adherence to the protocol.  Additionally, postop management on the inpatient floor was poorly implemented with several patients failing to have interventions completed according to the study protocol. Therefore only half the study patients had post-operative data collected.  Of those available, 50% were discharged on post-op day 2.

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Robotic Surgery: Overview, Economic Considerations, Public Policy Impact

Francis J. Podbielski, MD, MS, FICS, Clinical Professor of Surgery, University of Illinois at Chicago, Riverside, IL


Introduction:  The first surgical robot for standard clinical use was the “Arthrobot”; introduced in Canada in 1983 it was used for total hip arthroplasty.  In 1985 the PUMA 560”; was used to place a needle for a brain biopsy using CT guidance.  This was followed by the PROBOT”; in 1988, a system developed to perform prostate surgery.  Next, the “ROBODOC”; was introduced in 1992 to mill out precise fittings in the femur for hip replacement.  These initial advances paved the way for development of the robotic surgical platforms that are in use today.


Methods:  In the year 2000, approximately 1,000 robotic operations were performed in the United States.  By the end of 2014, 570,000 robotic operations had been performed in that single year.  The majority of procedures in 2014 were:  robot-assisted hysterectomies - 203,000 and prostatectomies - 125,000.  At the end of 2014, 3,266 systems were being used worldwide, 2,223 of which were in the United States (68%).  The total revenue for Intuitive Surgical in 2014 was $2.1 billion, 70% of which ($1.47 billion) was from purchases in the United States.  Current general surgical residents in the United States received formal robotic training which includes: simulation, animal laboratories, and hands-on mentored training by a senior attending.  Established surgical attendings wishing to start a robotic practice usually take a course sponsored by the company and then are proctored through a pre-determined number of procedures prior to performing robotic operations independently.


Results: Robotic surgery is an expensive technology.  The da Vinci Surgical System, (Intuitive Surgical), starts at about $600,000 (used) but can increase to as much as $2.5 million (new).  The platform has yearly maintenance fees that range from $150,000 to $220,000.  Addition of robot-specific instruments/accessories, can add $700 to $3,200 to a simple surgical procedure.  The average lifetime of a da Vinci robot is a maximum of seven years.  These factors have led even large, well-endowed, U.S. academic institutions to closely study the cost-effectiveness of robotic technology for general use in surgery, while continuing in their mission to develop advancement in medical technology.


(* all amounts listed are in U.S. dollars)


Financial Mistakes Made Most Often by the Smartest Person in the Room: Tax and Financial Stories for Surgeons Ears Only

Victoria Powell, JD, LLM, Attorney at Law; Partner, Powell Heymann LLC, Phoenix, AZ


Purpose: Educate surgeons from financial records, including tax returns, and self-reporting of peers at several career stages for the purpose of potentially avoiding future financial losses with long term professional and personal impact. 


Methods:  Select 5 (or more, presentation time permitting) of 18 in depth case studies of practice management problems in surgical practices across the United States, and reveal resulting financial insult to the doctors. Redact and analyze data evidencing financial mismanagement scenarios most common to surgeons.  Identify points in time when alternative behaviors could have avoided losses. Identify behaviors that could change to produce better results at the next stage or opportunity.


Results:  Foreseeable and therefore preventable problems occurred in the following areas:

1. Personal and professional partnerships and subsequent divorces

2. Medical and other real estate investments with leverage

3. Insurance and estate planning

4. Cash flow and debt management

5. Critical business and investment transactions with non-medical professionals

6. In all of the above areas, surgeons failed to obtain enough or the right information to inform their decisions.


Conclusions:  Avoiding unnecessary financial losses that are foreseeable should be high on the agenda of every surgeon.  Highly demanding careers result in high stress, high income, and very high taxes. With advanced lifestyle demands from social peers and family, this economic position provides a backdrop for a series of poor financial decisions over time, exacerbated by reactivity in solving them, due to lack of formal education and lack of time.   While surgeons have easy access to debt, they need to understand why this sets them up to be victims in a financial and legal environment uniquely designed to siphon profits from their outstanding earning capacity. Acknowledging limitations in abilities or education or vision is far from comfortable for surgeons, which is precisely why, in this author's opinion, working around your unique professional vulnerability in financial transactions can be financially so very rewarding.


Life of an Orthopedic Surgeon Motorcycle Crashes

John Romito, MD, Chief Medical Officer Overland Park Regional Medical Center, Leawood, KS


This presentation has the absolute data and X-rays of actual events as well as treatment of severely injured patients treated in a community based level ll trauma center. These are patients that were treated during a 1 year period.


New Liver Anatomy Based on the Portal Segmentation and the Drainage Vein Reconstructed by CT Generated 3-D Image

Munemasa Ryu, MD, FICS, Division of Surgery, Chiba Cancer Center Hospital, Chiba, Japan

We have evaluated the portal vein and hepatic vein branching systems by CT generated 3-D image. The main portal trunk bifurcates into the right and left portal veins (first-order portal branches). The blood supply of the caudate lobe is derived from these first-order portal branches. The left portal vein bifurcates into the left lateral branch (P2) and the left paramedian branch (umbilical portion: UP) (second-order portal branches). Then, the latero-inferior branches (P3) arise from the UP and coursed laterally, and the medial branches (P4) arise from the UP and coursed medially (third-order portal branches). The right portal vein bifurcates into the right lateral branch and the right paramedian branch (second-order portal branches). Them, the ventral branches arise from the right paramedian portal trunk and course ventrally while dorsal branches arise from the right paramedian portal trunk and course dorsally (third-order portal branches).


The hepatic venous system mainly consists of the three main hepatic veins: the right, middle and left hepatic veins, which are running along the right, main and left portal fissures respectively. In addition, the umbilical fissure vein is running along the umbilical fissure between the left and middle hepatic veins, and the anterior fissure vein is running along the anterior fissure between the middle and right hepatic veins. From the standing point of portal segmentation and the drainage vein, we propose the new liver anatomy that both the left and right livers should be divided into the three segments respectively, by adding the caudate lobe as one segment. The left liver is divided into three segments, which are designated as the latero-inferior segment (S2), latero-superior segment (S3), and medial segment (S4) as previously described by Couinaud. The right liver is also divided into three segments, which are designated as the anterior segment (ventral region of the right paramedian sector), middle segment (dorsal region of the right paramedian sector), and right lateral segment (posterior segment) as an alternative to Couinaud. The anterior fissure vein is running just border of anterior segment and middle segment same as umbilical fissure vein which runs between S3 and S4.


We will show some hepatic resections via anterior fissure approach.


Common Femoral Thromboendarterectomy and Profundaplasty: A Single Center Experience

Sibu Saha, MD, MBA, FICS, Professor of Surgery University of Kentucky, Lexington, KY


Peripheral Artery Disease treated by open procedure that is not easily amendable to endovascular approach.  The audience needs to be knowledgeable of current treatment.  After this presentation the learner should appreciate the value of the technique.  The audience should benefit from this presentation by being able to direct their patient for appropriate treatment.


Objective:  Peripheral artery disease (PAD) is common in our country and is typically treated by an endovascular procedure. However, occlusive disease of the common femoral artery is not easily amenable to endovascular approaches and requires an open procedure. We reviewed our experience with this procedure at the University of Kentucky.

Methods: With IRB approval, we analyzed data from the patient records for all patients that underwent a common femoral thromboendarterectomy and profundaplasty between November 2011 and March 2015 at the University of Kentucky.


Results:  During the study period, 100 common femoral thromboendarterectomy and profundaplasties were performed at the University of Kentucky. Patients had an average age of 65 years, an average BMI of 25, 37 were female, 73 had claudication, 63 had rest pain, and 33 had tissue loss. Sixteen patients had CFE only, 26 had CFE with inflow, 27 had CFE with outflow, and 31 had CFE with both inflow and outflow.


Sixty-nine patients received a patch, with the most common types being vein (26 patients), bovine (18 patients), and femoral artery (12 patients) . Thirty-seven patients were diabetics, 11had a history of CHF, 80 had hyperlipidemia, 89 had hypertension, 7 had chronic renal failure, 60 had a history of CAD, 41 had COPD, 90 had a history of smoking, 23 had a previous myocardial infarction, 18 had a previous CABG, 45 had a previous groin surgery, and 61 had a previous vascular surgery. Eleven patients died postoperatively, 17 had an amputation, 30 had a reinterventon, 42 had an ICU stay, 13 had prolonged intubation, 3 experienced a stroke, 2 experienced a myocardial infarction, 3 experienced postoperative bleeding, 8 had superficial wound infections, 7 had deep wound infections, 10  experienced would dehiscence , 5 had seroma, 3 had PNA, and 1had DVT. Patients who received a patch did not differ significantly on any pre- or peri-operative characteristics from those that did not receive a patch.


However, hospital length of stay differed significantly between patched and non-patched patients (Patch, median 6 days; Non-Patch, median 9 days; p-value = 0.034).


Conclusion: Common femoral thromboendarterectomy is safe and effective in this group of patients with advanced PAD and significant co-morbidity.


Complications of Chest Wall Non-union with Serratus Muscle Dehiscence

Tracy Sambo, MD, FICS (Jr.), General Surgery Resident, Presence St. Joseph Hospital, Chicago, IL


Introduction:  Chest wall non-union with or without lung hernia is an uncommon problem encountered after thoracotomy.  Predisposing factors include malnutrition, extreme physical exertion in the post-operative period, and poor surgical technique in closure of the chest at the time of operation.  Patients can present with a constellation of complaints including, pain, a palpable defect in the chest wall, and/or instability of the bony thorax.


Methods:  The patient is a 72-year-old woman with a history of a previous right upper lobe lobectomy approximately years prior in treatment of an early stage non-small cell lung cancer.  She underwent a re-do right thoracotomy, extensive pneumolysis, and right middle lobe lobectomy for a newly diagnosed lung malignancy.  Approximately three weeks after surgery while moving furniture she felt a snap in the region of her incision.  A palpable defect was noted, but she was largely asymptomatic until approximately three months after her initial operation when she presented with extensive subcutaneous emphysema.  At the time of exploration she was found to have dehiscence of her serratus anterior muscle and a large gap between her ribs.  She underwent a pneumolysis, primary re-closure of her ribs, and re-approximation of her serratus and lattisiumus dorsi muscles.  Her post-operative recovery was uneventful.


Discussion:  When confronted with a chest wall defect requiring closure either at the time of initial operation or later, option include repeat primary closure, a lattice weave of suture material, a bioprosthetic patch, or a prosthetic  patch.  Re-establishment of the contour of the chest can be achieved with a combination of metal bars and patch material.  Small, asymptomatic defects often require no operative intervention.


Prevention of Bowel Anastomotic Leak:  Reinforcement using Biologic Mesh

Larry S. Sasaki, MD, FICS, Bossier City, LA


Anastomotic leaks are a dreaded post-operative complication.  The literature is replete with studies that report leak rates from 0.5 to 12%.  Low colorectal anastomoses have higher leak rates reported as high as 15%.  Preliminary analysis has confirmed a reduction of anastomotic leaks using a biologic mesh wrap.  An extracellular matrix derived from porcine urinary bladder was applied and sutured to the anastomosis.  The functional intent of this mesh was to facilitate a constructive remodeling process with restoration of normal site-appropriate tissue.  One hundred and fifty-five (155) patients with bowel anastomoses were reinforced with a porcine biologic mesh wrap.  Bowel anastomoses included entero-enterostomy, ileo-colic, ileo-ectal, ileo-anal, colo-colostomy, colo-rectal, and colo-anal anastomoses.  Preliminary analysis has indicated a statistically significant reduction of anastomotic leak.  This presentation will discuss the technique for application, and these preliminary findings.



Surgical Access For All - The European Approach

Frank P. Schulze, MD, FICS, Surgeon-in-Chief, St. Marien-Hospital, Mulheim, Germany;


Introduction: More than 234 million operations are performed worldwide per year. However, there is an estimated need of more than 320 million surgeries annually. Thus, closing the gap requires some 100 million additional procedures worldwide each year. However, up to five billion people cannot access safe, affordable, and in-time surgery. In this presentation the current situation to surgical access is analysed and the options for improvements are presented and discussed with a special focus on the European view, approach and commitment.


Methods: PubMed, the Cochrane Library, the WHO database, and the European Commission database were screened for publications and available data on global surgical access and humanitarian surgery. In addition to this, data from humanitarian surgical groups like the International College of Surgeons (ICS), International Federation of Red Cross and Red Crescent Societies (IFRC), Médicins Sans Frontières (MSF) and further organisations were collected and analysed.


Results: The global burden of disease is estimated to be around 30% surgical. The number of people lacking adequate and in-time access to surgical care is estimated to be 2 - 5 billion people worldwide per year. More than 400 NGOs providing surgery in low- and middle-income countries (LMICs) have been identified. The vast majority of the NGOs providing surgical care for LMICs is based in the USA, followed by European countries (UK, France, Germany, Italy, Sweden). The most common specialty provided is general surgery (17%), followed by gynaecology & obstetrics (13%), plastic surgery (11%), ophthalmology (10%), and further specialties and subspecialties.


Conclusion: Surgical access for all is a dream that yet has to become true. The more than 400 NGOs are important parts in this to date unsolved puzzle. Further efforts and alliances are needed and have to be supported by politics, health systems, money-givers, and individuals to provide the essential surgical care as requested by the ‘Global Initiative for Emergency and Essential Surgical Care‘ (GIEESC) of the WHO.


Leadership…Everything Starts at the Top

Steven Seroka, USAF Colonel (ret.), National Defense Fellow, Air War College, Air Command and Staff College, School of Advanced Strategy Development, Las Vegas, NV


The most important yet least understood role in business, Leadership.  Every ‘ounce’ of leadership produces ‘pounds’ of return. Active, Engaged, Respectful Leadership will make your bottom-line jump off the page! Every action, word and attitude of a leader ripples throughout an organization... both the good and bad! And I do mean 'everything'...don’t fool yourself into thinking otherwise.  Effective Leadership is Active, Engaged and Respectful and is only 5 steps. Learning the steps is easy... perfecting them is a lifetime endeavor…but the knowledge comes first.   Oh, and there two critical components... learn what those are and jump on leadership opportunities without trepidation!! 


Let's face it...MD's are not known for their leadership or their team building ability...yet that is what they are tasked to do everyday.   But don't be put off...MD's are in good company across the country.  Corporations and Businesses of every type are starving for effective leadership.  Yet, there are strikingly few good examples to learn from.  Let's start here...


Without question...The learner will be able to immediately begin improving the performance, efficiency and profit of their organization.


Exploring the Relationship Between Surgical Care Capacity and Output in Ghana: The Hidden Roles of Non-Material Structures and Processes

Barclay Stewart, MD MscPH, Surgical Resident, University of Washington, Seattle, WA


Surgical capacity assessment results have served as proxies for surgical output in low- and middle-income countries (LMICs). We sought to explore the relationship between surgical care capacity and output (i.e., number of operations performed per year and operation rate per 100,000 popution) in Ghana to improve our understanding of how to better assess capacity and, ultimately, strengthen health systems to meet surgical needs.


Surgical care capacity assessments were performed at 37 hospitals nationwide (25 first-level, 9 regional, and 3 tertiary hospitals) using World Health Organization guidelines; availability of 21 essential resources was used to create a composite capacity score that ranged from 0 (no availability of essential resources) to 63 (constant availability of essential resources) at each hospital. Data on surgical specialty availability (e.g., availability of specialty trained surgeons), number of hospital beds, number of functional operating theaters, and operations performed over one year at each hospital were collected. Ghana Statistical Service and Ministry of Health provided hospital catchment populations. The relationship between capacity, surgical specialty coverage, and output was explored with zero-truncated generalized negative binomial regression modeling.


The median surgical capacity score was 31 [interquartile range (IQR) 27    40; range 13 - 60]. All hospitals had medical officers who were able to perform some degree of surgical care; 5 hospitals had one surgical specialty available (14%); 11 had two specialties available (30%); and 8 had more than two specialties available (22%). The median number of operations per year was 1,580 (IQR 736 –  2,167) at first level hospitals; 1,767 operations (IQR 1,018    2,643) at referral hospitals; and 12,509 operations (IQR 3,773    22,260) at tertiary hospitals. Further, median number of operations per 100,000 catchment population per year (i.e., operation rate) was 1,028 (IQR 725  – 1,746) at frst level hospitals; 105 operations per 100,000 population (IQR 79 - 157) at referral hospitals; and 445 operations per 100,000 population (IQR 150 - 595) at tertiary hospitals. There was no correlation between capacity and number of operations performed per year (p=0.32) or rate of operations per 100,000 population per year (p=0.29), even when adjusted for specialty availability, number of hospital beds, and number of functional operating theaters.


Global Surgery - Challenges, Disparities, Initiatives, and Prospects - an Interim Report from a Sub-Saharan Perspective

John Tarpley, MD, FWACS, FACS, Professor of Surgery & Anesthesiology (Emeritus), Vanderbilt University School of Medicine and Vanderbilt Institute for Global Health; Visiting Professor, Surgery, University Teaching Hospital of Kigali (Rawanda), Nashville, TN


This is an interim report from Sub-Saharan Africa.  From a broad 'surgical' perspective there are at least six major surgical challenges to providing access to care in Sub-Saharan Africa (SSA): Safe Anesthesia and Airway Management, Trauma, Women's Health, Cancer, Paediatric Surgery, and Analgesia.  The disparities between SSA and what pertains in High Income Countries will be highlighted.  In 2015-2016 into this year Global Surgery has witnessed a burgeoning of interest, activity, and initiatives in addressing the challenges and disparities: Edition 3 of Disease Control Priorities, The Lancet Commission, the World Health Assembly Declaration 68.15, and the G4 Alliance among others.  Academic Global Surgery is emerging as a vocation/career pathway.  Given great enthusiasm, reality abounds and the challenges are daunting.  With cautious optimism we confront major issues in seeking to achieve The Lancet Commission's laudatory goals for 2030 including their roadmap for the role of high income country actors.


Expanding the Scope of Minimally Invasive Thoracic Surgery: Unique Advantages of Robotic Approach

Wickii Vigneswaran, MD, MBA, FICS, Professor Thoracic and Cardiovascular Surgery, Director of Thoracic Surgery, Loyola University Health System, Maywood, IL


Introduction: Minimally invasive approach for lung resection and mediastinal surgery is widely applied and appears to have significant advantages over open thoracotomy approach. Traditional Video Assisted Thoracic Surgery (VATS) however is limited by rigid instrumentation and 2D vision. The da Vinci robotic system appears to overcome these limitations.  The increased magnification, 3D vision and instrument maneuverability in tight spaces allow this technology to be expanded in Thoracic Surgery.


Methods: Several techniques are currently employed for performing surgery in the chest. We have evolved our robotic technique from our extensive experience with VATS approach.  The da Vinci system allows one to perform detailed and complex surgery in the thoracic cavity with more confidence and ease. We will describe our experience of the expanded utilization of robotic operative procedures with short clips of videos and describe others including review of the current literature to allow audience participation.


Results: Intuitive instrumentation, 3D vision, higher definition, greater flexibility and ergonomics render the surgery easier and offer an opportunity to explore new frontiers.


Conclusion: Da Vinci robotic approach allow expanded utilization of this minimally invasive technique that are not readily available to video assisted thoracoscopic surgical approach, appear to result in shorter hospital length of stay, early return to full activity,  low morbidity and improved quality of life.

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A Retrospective Controlled Clinical Study of Laparoscopic-Assisted and Open Complete Mesocolic Excision in Right-Side Colon Cancer
Minhao Yu, MD
, Department of Colorectal Surgery, Renji Hospital, School of Medicine, Jiaotong University, Shanghai, China

Objective: To investigate the efficacy of laparoscopic-assisted and open complete mesocolic excision (CME) in right-side colon cancer.

Method: The clinical data of all paitents with right colon cancer was retrospectively analyzed from January 2010 to December 2014 in gastrointestinal surgery department of Renji Hospital, School of Medicine, Shanghai Jiaotong University (102 patients underwent laparoscopic-assisted CME and 116 patients underwent open CME). Short-term and oncologic outcomes were compared between the groups.

Result: The baseline information was not significantly different between the groups (P>0.05). As compared to open group, the patients in Laparoscopic-assisted group had longer operating time (155.2± 4.17 vs. 140.1±4.00 minP=0.0096), but less bleeding (102.6±7.37 vs. 145.9±12.23 mlP=0.0037), more retrieved lymph nodes (12.17±0.39 vs. 10.78±0.42P=0.0168), faster recovery course including shorter time to liquid diet (2.91±0.47 vs. 3.62±0.41 dayP=0.034) and shorter time of postoperative hospital stay (10.59±0.57 vs. 14.13±0.52 dayP =0.041). No significant difference was observed in the rate of complications between the groups. The period of follow-up was no significant difference in the groups (38.83±1.73 vs. 30.74±1.60 month, P>0.05). The five-year survival rate was significantly better for patients in laparoscopic-assisted group (89.81% vs. 82.22%P=0.0482).

Conclusion: For patients with right-side colon cancer, laparoscopic-assisted CME would be a safe and efficient alternative, and also better for survival.