Transumbilical laparoscopic cholecystectomy: a novel technique.

OBJECTIVE: To describe a novel technique for performing laparoscopic cholecystectomies using no proprietary or specially designed equipment, while still minimizing the incision and leaving a nearly invisible scar. DESIGN: Retrospective review. SETTING: Community teaching hospital. PATIENTS: Twelve patients having uncomplicated laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: Number and appearance of postoperative scars. RESULTS: Twelve attempts to perform the procedure with our new technique were completed successfully. None of the patients required conversion to the standard technique, which requires additional ports. All of the patients were pleased with their results. No identifiable mark was visible in the right upper quadrant of any of the patients; at the 2-week follow-up, the umbilical incisions were nearly invisible, even to the patients. CONCLUSION: This novel technique can be performed safely and effectively while minimizing the number and extent of incisions.

Outpatient surgery centers draw cases away from hospitals, impact resident training volume.

PURPOSE: Across the United States, ambulatory surgery centers (ASCs) are increasing in both number and surgical volume. This trend has been the focus of debate regarding reimbursement and patient safety, as well as surgical productivity and efficiency. However, the impact on surgical resident training caused by this shift toward outpatient surgery in nonhospital settings has not been studied. We reviewed data reported by our hospital and by local surgery centers as well as the case logs of the surgical residents at our institution to determine whether a negative effect on resident case volume has occurred. METHODS: We conducted a retrospective review of our PGY-1 through PGY-3 level surgical residents' case logs for 3 consecutive academic years, from July 2004 through June 2007. We evaluated a group of common outpatient procedures that are now also being performed in stand-alone surgical centers in our area, such as breast biopsies, incision and drainage, hernia repair, colonoscopy, and esophagogastroduodenoscopy (EGD). The data were tallied by academic year and compared over time. In addition, we analyzed data reported to state agencies by our hospital and local surgery centers over the last 6 calendar years for any trends in case volume. By evaluating 2 different independent data sets for the same endpoint, we could evaluate our hypothesis twice. RESULTS: When evaluating state-reported data for the defined cases, a significant decrease was observed in the total number of cases performed at Easton Hospital, Easton, Pennsylvania, each year between 2003 and 2006 (p < 0.0001). When reported cases by procedure category for 2003 versus 2005 only (because of incomplete data from ASCs in 2004 and 2006), a significant decrease was observed as well for certain specific procedures as follows: colonoscopy (p < 0.0001), inguinal/femoral hernia (p = 0.04), excision of skin lesion (p = 0.0022), and incision/drainage (p < 0.0001). When comparing resident reported data, significant decreases were observed in the number of hemorrhoidectomies, breast biopsies, skin grafts, carpal tunnel releases, and excision of skin lesions performed by residents during each academic year from July 2004 to June 2007. CONCLUSIONS: Our residents historically have gained all of their outpatient surgery experience from procedures performed at our home institution. With the recent surge of stand-alone surgical centers, many outpatient procedures are being performed outside of the hospital in centers where our residents do not rotate. Although current residents in our program are performing enough cases to fulfill the ACGME required minimums, the number of cases is significantly decreased because of cases performed by stand-alone surgical centers.

Burkitt lymphoma presenting as colonic ischemia and overwhelming sepsis.

Lymphomas may occasionally present as acute surgical emergencies in children, most commonly because of obstruction, intussusception, or direct bowel invasion. We present the case of a 14-year-old adolescent boy who presented with septic shock and was found to have necrosis of the cecum because of a Burkitt lymphoma. The cause of the ischemia appeared to be mesenteric infiltration and subsequent vascular compromise of the bowel. We discuss the management of this patient and present a review of the literature.

Charcoal peritonitis causing chronic pelvic pain: a unique complication following bariatric surgery.

Routine pathologic examination of a specimen transformed a common diagnosis of endometriosis into a search for an unusual cause of recurrent pelvic pain. Laparoscopy was suspicious for endometriosis, but instead on microscopic examination a black pigment of unknown origin was present. In a subsequent interview with her gynecologist the 38-year-old patient divulged a previous Roux-en-Y gastric bypass (RYGBP), followed 8 weeks later by a suicide attempt by overdosing on medication, treated with charcoal gastric lavage. Her tiny gastric pouch was perforated and she developed charcoal peritonitis. If the emergency room physicians had been aware of her recent RYGBP, they may not have performed the lavage, and if the gynecologist had been aware of the history, she may not have been incorrectly diagnosed endometriosis.