EOHF

AfsdthdtbmptgndmpAmnfth

hpsltmrct

clatTt

©P

EDITORIAL

nough, but Not Too Much:r, Are We the Dinosaurs?David Reines, MD, FACS, FCCM, Russell P Seneca, MD, FACS, FCCM

alls Church, VA

ift3tqcldo

sfmRRsfvtpgs

AmtNktaimTrap

c

s surgery evolves over the next decade, we will see aurther acceleration of the shift toward minimally inva-ive surgery that began in the late 1980s with the intro-uction of laparoscopic cholecystectomy. The questionhen was: How many laparoscopic procedures do youave to do to be competent? The question for the nextecade will be: How many open procedures do you haveo do to be competent? We are truly facing a change inasic standards with the exponential growth of mini-ally invasive surgery. What started out as a novel ap-

roach has turned into an explosion in technology,echnique, and attitude. The effects on our training pro-rams are as yet unknown, but the shift from open tech-iques to minimally invasive surgery has been tremen-ous. The archetypal example of the latest impact ofinimally invasive surgery is the effect laparoscopic ap-

roaches have had on bariatric or obesity surgery. Themerican Society for Bariatric Surgery has grown inembership from 258 in 1998 to 1,070 in 2003; the

umber of bariatric procedures in the US has grownrom 16,000 in the early 1990s to a projected 144,000his year.1 Laparoscopic, minimally invasive proceduresave made this the fastest growing area of surgery.Although the data show that open, tension-free mesh

ernias are an excellent and cheaper form of hernia re-air, laparoscopic hernias are growing in popularity. Inome hospitals, up to 50% of appendices are removedaparoscopically, more than 75% of gallbladders areaken out through a scope, and many diseased, nontrau-atized spleens are removed minimally invasively. Lapa-

oscopic colectomy has proved to be acceptable for can-er,2 and laparoscopic donor nephrectomy has becomehe procedure of choice for living donors.

Conversion rates for procedures vary significantly ac-ording to procedure, operator, and high-volume versusow-volume centers. Studies from several countries giveconversion rate from laparoscopic to open cholecystec-

omy at 9.5% to 4.8%, with an average of 5% to 10%.3-5

hat means that an average chief resident will do be-

ween 5 and 10 open gallbladder procedures during res- w

9302005 by the American College of Surgeons

ublished by Elsevier Inc.

dency. In a recent study from Italy, the conversion rateor appendectomy was 9.7% because of severe peritoni-is or anatomy.6 Gastric bypass conversion is down to% according to a recent study.7 Hernias and adrenalec-omy rarely need conversion, and left colectomy re-uired conversion in 4.9%.8 The US randomized colonancer trial had a 21% conversion to open rate amongaparoscopic colectomies.2 Even perforated gastroduo-enal ulcers need to be converted to an open procedurenly 12.5% of the time.9

We have established learning curves for many laparo-copic and now for robotic procedures, but the questionor the educators of future surgeons has to be: Howany open procedures do you need to do to be safe?amifications of this include a revision of Residencyeview Committee requirements for procedures, a revi-

ion of the oral and written boards, and a new definitionor general surgery. Why do we need fellowships in ad-anced laparoscopy or even bariatrics if the current trendoward laparoscopic surgery continues? The attempt toull out the cardiothoracic and vascular trainees fromeneral surgery makes absolute sense if the majority ofenior surgical residency is spent behind a camera.

So let us look at facts: The majority of the leaders inmerican surgery were trained in the era when mini-ally invasive surgery was in its infancy. The new direc-

ors and chairs are coming in at a time when the “open”issen is an anachronism. How many chief residents

now how to perform a common duct exploration? (Dohey need to?) Giving the oral boards recently, I wasmazed to find that the treatment for a strangulatednguinal hernia requiring a bowel resection was “vicryl

esh,” because very few knew what a McVay repair was.he treatment of choice for a perforated ulcer was a lapa-

oscopic repair. The number of open gastrectomies wasbout equivalent to the average number of “Whipples”erformed.

How many “open” ventral hernias does the up-and-oming resident need when he can take down adhesions

ith scissors (or bovie or harmonic scalpel) through a

ISSN 1072-7515/05/$30.00doi:10.1016/j.jamcollsurg.2005.03.024

sstnctwtltlwab

Srtptvssgsnbh

hjtw

R

1

2

3

4

5

6

7

8

9

931Vol. 200, No. 6, June 2005 Reines and Seneca Editorial

cope? The question becomes more important as fellow-hips turn out more advanced laparoscopists who will, inurn, teach residents more advanced techniques. Theew generation of laparoscopic surgeons, through aombination of patience, guts, and skill, can completehe majority of operations and address complicationsithout opening the patient. Who would have thought

hat you could patch a laparoscopic gastric bypass leakaparoscopically and avoid a laparotomy most of theime? What will happen to surgeons who have seen 200aparoscopic appendices, hernias, and gastric bypasses,ho realize that they can’t do a procedure safely throughscope because of inflammation or bleeding? Will theye prepared for the open procedure?

We propose that the RRC and the American Board ofurgery look at their requirements for essential cases andevise them to reflect the rapid rise in minimally invasiveechniques. We can find no data on the number of openrocedures necessary to make a competent surgeon, onlyotal numbers. The RRC doesn’t even require “ad-anced” laparoscopic cases. We need to talk to the youngurgeons and the experts who perform primarily laparo-copic procedures, and ask what is necessary to train theeneral surgeon of the future. If general surgery is tourvive, minimally invasive bariatric procedures, sple-ectomy, Nissen fundoplication, and colectomy need toe taught in residencies. We still need to teach surgeons

ow to do a hand-sewn anastomosis, close an incisional

ernia, and take out a gallbladder through an incision,ust in case there is a reason to abandon a scope and do ithe old fashioned way. Oh yes, and do this in 80 hours aeek.

EFERENCES

. Steinbrook R. Surgery for severe obesity. N Engl J Med 2004;350:1075–1079.

. Clinical Outcomes of Surgical Therapy Study Group. A compar-ison of laparoscopically assisted and open colectomy for coloncancer. N Engl J Med 2004;350:2050–2059.

. Glavic Z, Begic L, Simlesa D, Rukavina A. Treatment of acutecholeycystitis: A comparison of open vs laparoscopic choleycys-tectomy. Surg Endosc 2001;15:398–401.

. Livingston EH, Rege RV. A nationwide study of conversion fromlaparoscopic to open cholecystectomy. Am J Surg 2004;188:205–211.

. Kologlu M, Tutuncu T, Yuksek YN, et al. Using a risk score forconversion to open cholecystectomy in resident training. Surgery2004;135:282–287.

. Vettoretto N, Balestra L, Pettinato G, et al. Introduction of lapa-roscopic appendectomy: A retrospective comparison with theopen technique. Chir Ital 2004;56:409–414.

. Oliak D, Owens M, Schmidt HJ. Impact of fellowship trainingon the learning curve for laparoscopic gastric bypass. Obes Surg2004;14:197–200.

. Lezoche E, Feliciotti F, Guerrieri M, et al. Laparscopic versusopen hemicolectomy. Minerva Chir 2003;58:491–502.

. Seelig MH, Seelig SK, Behr C, Schonleben K. Comparison be-tween open and laparascopic technique in the management ofperforated gastroduodenal ulcers. J Clin Gastroenterol 2003;37:

226–229.