Monday, June 20, 2005

The Open Abdomen -- An Anachronism?

An interesting editorial was published in the Journal of the American College of Surgeons this month (subscription required) entitled "Enough But Not Too Much: Or, Are We The Dinosaurs?" (by H. David Reines, M.D. and Russell P. Seneca, M.D.). It is actually another expression of a concern that many academic, as well as non-academic, surgeons have been mulling over the past few years: are current surgery residents getting enough exposure to "open" surgery in this era of minimally invasive surgery?

As laparoscopic techniques have advanced over the past 10-15 years, they have achieved wide acceptance. Initially, with laparoscopic cholecystectomy, there was considerable concern that surgeons well out of their training would not receive appropriate instruction and preceptorship to perform these operations well. I was fortunate to spend a year during the middle of my residency learning and teaching courses on these (then new) techniques, and this was a concern expressed often by the organizers of those courses. As a result, guidelines were developed to ensure that adequate training was available to surgeons out in practice, allowing patients access to physicians well-versed in this rapidly expanding field. Now, procedures such as laparoscopic splenectomy, colectomy, fundoplication, appendectomy, and bariatric surgery are done commonly in both the academic and private practice arena.

Now, any surgery resident worth his or her salt is going to try to get as much minimally invasive surgery experience as possible. But does that leave them with enough "open" surgery experience? For example, does the average surgery resident finish training with many common duct explorations? Open Nissens? Open cholecystectomies? This is not a moot point, as the "easy" cases will always be done laparoscopically --- when we convert to an open procedure, you can bet that it is because the operation is much more difficult, due to anatomy, bleeding, etc.

So, now we have come full circle. Some in teaching programs are now wrestling with how to ensure their residents get adequate training in open procedures (from the editorial):

We propose that the RRC (Residency Review Committee) and the American Board of Surgery look at their requirements for essential cases and revise them to reflect the rapid rise in minimally invasive techniques. We can find no data on the number of open procedures necessary to make a competent surgeon, only total numbers. The RRC doesn'’t even require “advanced” laparoscopic cases. We need to talk to the young surgeons and the experts who perform primarily laparoscopic procedures, and ask what is necessary to train the general surgeon of the future. If general surgery is to survive, minimally invasive bariatric procedures, splenectomy, Nissen fundoplication, and colectomy need to be taught in residencies. We still need to teach surgeons how to do a hand-sewn anastomosis, close an incisional hernia, and take out a gallbladder through an incision, just in case there is a reason to abandon a scope and do it the old fashioned way. Oh yes, and do this in 80hours a week.
In the best of all possible worlds, newly minted surgeons would take jobs with older, more established surgeons that provide expertise and help ("mentoring," to use the current buzz word) -- here, again, I was and continue to be extremely fortunate in this regard. That is probably not attainable for many graduating residents. It is hard to conceive a situation where the RRC would mandate a certain percentage of cases to be done "open," either: can you imagine the consent form for patients at teaching facilities then ---- "if we determine that the resident helping with this operation has insufficient experience with the open technique, you'll get a bigger incision." That would be about as popular as Howard Dean at a NASCAR event.

In the long run, this type of concern in the era of the mandated 80 hour work week may lead to a push to lengthen an already long residency (see Bard Parker). My proposal would be to try to shift some of the operative experience away from those residents travelling down a different training pathway (i.e., towards plastic surgery, urology, etc.). While that might provide some limited help, it certainly would wreak havoc with those trying to juggle schedule to ensure they don't go over that 80 hour limit.