From Hippocrates to Palmaz-Schatz, the history of carotid surgery.

The extracranial carotid artery is the most common site for peripheral vascular procedures. Although the association of carotid disease and neurologic dysfunction was understood by the ancient Greeks, over 1700 years would pass before the relevant anatomy was described. In the 16th and 17th centuries, attempts at treatment of carotid injury and aneurysm by ligation were met with extremely high rates of stroke and death. It is not until the mid 20th century, with the introduction of carotid angiography and improved vascular surgical techniques, that the era of reconstructive carotid surgery begins. We present a synopsis of the history of carotid surgery from ancient times to present day.

Standardizing laparoscopic procedure time and determining the effect of patient age/gender and presence or absence of surgical residents during operation. A prospective multicenter trial.

BACKGROUND: Most of the expense of laparoscopic cholecystectomy (LC) is incurred while the patient is in the operating room (OR). Half of this operating room cost is equipment and the other half is personnel. What is an acceptable LC procedure time and how much variation is there? What are the effects of age, gender, and expertise on the mean LC procedure time? METHODS: A prospective, multicenter gathering of LC procedure times and task component times was performed through the cooperative effort of members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) at 11 hospitals. The effect of LC time of age, gender, and surgical resident was recorded. RESULTS: The mean LC time for 359 cases was 73 +/- 28 min. The percent of this LC time for the following component tasks included: to place and remove trocars, 34%; total dissection time, 40%; intraoperative cholangiogram, 15%; and removing the gallbladder, 7%. Age and gender did not change LC time, but the presence of a surgical resident prolonged LC time from 53 to 79 min due to an increase in all LC component task times. CONCLUSIONS: LC time was globally calibrated in 11 North American hospitals and was found to be affected by expertise but not by gender or age. The mean and standard deviation of LC time can be used for purposes of self-assessing quality performance.

Management and long-term follow-up of patients with positive cholangiograms during laparoscopic cholecystectomy.

BACKGROUND: With a goal of minimal invasion during laparoscopic cholecystectomy, the surgeon confronts a judgement decision if the intraoperative cholangiography (IOC) is positive for common bile duct (CBD) stones. The options are postoperative endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic papillotomy (EP), transcystic laparoscopic techniques (LAP), open CBD exploration, or clinical observation. PATIENTS AND METHODS: To gather this information, we reviewed the clinical course and IOC of 55 patients with positive IOC during laparoscopic cholecystectomy. Long-term follow-up (1.8 years) was obtained in 50 patients. RESULTS: After review, 48 patients were felt to have CBD stones, and a LAP without choledochoscopy was the initial management in 32 (67%) patients. The remaining patients underwent EP (n = 10), CBD exploration (n = 1), or observation (n = 5). By discharge, 19 (59%) of the 32 LAP patients were successful and had avoided EP while the success rate at follow-up was 48% (14/29). There were no complications after LAP, but we observed a 9.5% (2/21) post-EP pancreatitis rate that required readmission. The success rate for CBD stone clearance with LAP was associated with single stones (87%) and surgeon experience (100% in the last year). The average hospital stay was 1.7 days for LAP and 3.3 days for EP. CONCLUSIONS: LAP is safe and eliminates the need for EP in the majority of cases. Although EP is more often successful, it results in a longer hospital stay with an increased risk of complication. We recommend LAP as the initial procedure of choice for a positive IOC.