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[The identity of general surgery].
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A structure for general surgery.
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Endoscopy training in a general surgery program. Results of a survey.
To assess the role of adequate fiberoptic endoscopy training in a general surgery program, a survey was conducted of all graduates of one such program in which supervised endoscopy training was provided for each senior resident. Seventy-two percent of the general surgeons polled performed fiberoptic studies in their practice, including 53% who used upper gastrointestinal endoscopy and 44% who used colonoscopy. The development of competence depended largely on an adequate case load and the availability of supervision. Overall, training in endoscopy was considered essential by 70% of the trainees regardless of their eventual practice. Those not using endoscopy were generally located in metropolitan areas where consulting gastroenterologists were readily available. We conclude that the continued provision of training in fiberoptic endoscopy is justified by its frequent use in clinical practice and by the perception of graduates that it is a necessary component of surgical education.
Robotics and systems technology for advanced endoscopic procedures: experiences in general surgery.
The advent of endoscopic techniques changed surgery in many regards. This paper intends to describe an overview about technologies to facilitate endoscopic surgery. The systems described have been developed for the use in general surgery, but an easy application also in the field of cardiac surgery seems realistic. The introduction of system technology and robotic technology enables today to design a highly ergonomic solo-surgery platform. To relief the surgeon from fatigue we developed a new chair dedicated to the functional needs of endoscopic surgery. The foot pedals for high frequency, suction and irrigation are integrated into the basis of the chair. The chair is driven by electric motors controlled with an additional foot pedal joystick to achieve the desired position in the OR. A major enhancement for endoscopic technology is the introduction of robotic technology to design assisting devices for solo-surgery and manipulators for microsurgical instrumentation. A further step in the employment of robotic technology is the design of 'master-slave manipulators' to provide the surgeon with additional degrees of freedom of instrumentation. In 1996 a first prototype of an endoscopic manipulator system. named ARTEMIS, could be used in experimental applications. The system consists of a user station (master) and an instrument station (slave). The surgeon sits at a console which integrates endoscopic monitors, communication facilities and two master devices to control the two slave arms which are mounted to the operating table. Clinical use of the system, however, will require further development in the area of slave mechanics and the control system. Finally the implementation of telecommunication technology in combination with robotic instruments will open new frontiers, such as teleconsulting, teleassistance and telemanipulation.
General surgery programs in small rural New York State hospitals: a pilot survey of hospital administrators.
CONTEXT: Hospitals play a central role in small rural communities and are frequently one of the major contributors to the local economy. Surgical services often account for a substantial proportion of hospital revenues. The current shortage of general surgeons practicing in rural communities may further threaten the financial viability of rural hospitals and communities. PURPOSE: To describe hospital administrators' perceptions regarding the current state of general surgery programs at small rural hospitals in New York State, including the impact that surgical services have on hospital financial viability. METHODS: A list of hospitals belonging to the rural hospitals group of the Healthcare Association of New York State was obtained to determine prospective survey recipients. Sixty-eight administrators at each of the identified hospitals were subsequently surveyed and 38 respondents met all inclusion criteria. FINDINGS: Approximately 87% of hospital administrators perceive that the general surgery program is critical to the hospital's financial viability. Forty percent of respondents report that they would be forced to close the hospital if the surgical program was lost. Among the 42% of administrators trying to recruit a general surgeon, almost two thirds have been searching for more than 1 year. CONCLUSIONS: According to the perceptions of hospital administrators, the financial viability of rural hospitals in New York State depends in large part on their ability to provide surgical services. Additionally, general surgeons appear to be in high demand at a significant number of the surveyed institutions.
[Course of pregnancies and labors in a department of general surgery. A prospective study of pregnancies during a 1-year period at Hørsholms hospital].
The complications of pregnancy and delivery in a material consisting of 841 women without obstetric risk factors were investigated. The deliveries were planned to take place in a department of general surgery with a specialist obstetrician. Seventy-five women (8.9%) were transferred to a specialized obstetric department before delivery, 14 women (1.7%) because of imminent premature delivery. In addition, 69 women were transferred because of removal or their own wish for transfer. A total of 631 patients (90.5%) were delivered vaginally and 66 (9.5%) were delivered abdominally. In thirty-five of these, caesarean sections were performed during the course of delivery. In 34 deliveries (5.1%) vacuo extraction was used. Among 181 women (27.1%), unexpected complications occurred, 80 of these women (12.0%) requiring emergency treatment. A total of 697 infants were delivered. One infant died before delivery because of placental separation. Twenty-two infants (3.2%) were transferred to a paediatric department during the neonatal period, three because of asphyxia. Three of the liveborn infants (0.4%) had Apgar scores at 1 minute between 0 and 3, 40 infants (5.7%) had scores between 4 and 6. After 5 minutes, no infants had Apgar scores between 0 and 3, but three infants had scores between 4 and 6. It is concluded, that the low perinatal mortality and morbidity might indicate, that deliveries in a department of general surgery are safe, provided a specialist obstetrician is available and the rules of referral strictly observed.
The feasibility of adopting laparoscopic incisional hernia repair in general surgery practice: early outcomes in an unselected series of patients.
A laparoscopic approach to incisional hernia repair has been shown to be safe and effective in selected patients. We report our early outcomes following laparoscopic ventral/incisional hernia repair (LVHR) in an unselected series of patients encountered in general surgery practice. All patients referred with incisional hernia were offered a laparoscopic repair using prosthetic mesh. Patients were not excluded from laparoscopic approach on the basis of age, previous surgery, defect size, intraperitoneal mesh, body mass index (BMI), comorbidities, or abdominal wall stomas. We followed 28 consecutive patients who underwent LVHR (17 primary, 11 recurrent hernias). Laparoscopic repair was completed in 27 patients with a mean operative time of 141.6 +/- 11.9 minutes. There were no intraoperative complications. The mean size of the abdominal wall defects was 153.4 +/- 27.5 cm and the mean mesh size was 349.2 +/- 59.1 cm. The mean hospital stay was 3.7 +/- 0.3 days. Nine patients developed large wound seromas; all spontaneously resolved. Our experience suggests that LVHR is feasible as a primary approach to most incisional hernias encountered in general surgery practice.
[Enoxaparin in the prevention of deep venous thrombosis in general surgery].
Because of their pharmacologic advantages Low Molecular Weight Heparins (LMWH) are more and more used in the prevention of deep venous thromboembolic disease. Among LMWH, enoxaparin (Lovenox Pharmuka) efficacy has been assessed in several clinical trials since 1986, including more than 10,000 patients. Two of them were carried out in patients undergoing general surgery. The first one was performed in 1988 by M Samama et al on about 800 patients which concluded that enoxaparin (in one 20 mg daily s.c. injection) was at least as effective as standard prophylaxis with Unfractionated Heparin (U H), (three 5,000 IU daily s.c. injections). Second trial, coordinated by S Haas in 1988 on more than 8000 patients confirmed safety and efficacy of enoxaparin in prevention of post-operative thrombosis. These trials corroborate those carried out in orthopaedic surgery with enoxaparin: efficacy at least as effective as UH, with only one daily s.c. injection; mild biologic follow up (particularly, coagulation tests are useless with usual doses); a same dosage for all patients (20 mg daily s.c. injection in general surgery and 40 mg daily in orthopaedic surgery) independent of patient's weight. This prescription has to be started 12 hours before surgery with 40 mg and 2 h before with 20 mg.
[Robotics in general surgery: personal experience, critical analysis and prospectives].
Today mini invasive surgery has the chance to be enhanced with sophisticated informative systems (Computer Assisted Surgery, CAS) like robotics, tele-mentoring and tele-presence. ZEUS and da Vinci, present in more than 120 Centres in the world, have been used in many fields of surgery and have been tested in some general surgical procedures. Since the end of 2003, we have performed 70 experimental procedures and 24 operations of general surgery with ZEUS robotic system, after having properly trained 3 surgeons and the operating room staff. Apart from the robot set-up, the mean operative time of the robotic operations was similar to the laparoscopic ones; no complications due to robotic technique occurred. The Authors report benefits and disadvantages related to robots' utilization, problems still to be solved and the possibility to make use of them with tele-surgery, training and virtual surgery.
General surgery in crisis--comparatively low levels of remuneration.
INTRODUCTION: Several factors, including comparatively low remuneration, may be responsible for the decline in applicants to general surgery. In this study, the levels of remuneration of general surgeons in the state sector were compared with other professionals in the state sector and general surgeons overseas. METHODS: The study involved a combination of desk research and structured interviews. The Paterson system of job evaluation was used to compare general surgeons with other professionals. The levels of remuneration of general surgeons in the state sector were compared with those of other professionals. RESULTS: There was a significant difference in the levels of remuneration between state-employed medical practitioners and other professional positions such as legal professionals, municipal managers and airline pilots. At senior levels (senior specialist) the remuneration was only +/- 55% of that paid to the selected comparator group. There was also a significant differential between the remuneration of state-employed general surgeons and their overseas counterparts. CONCLUSION: Levels of remuneration of state-employed medical practitioners continue to lag behind other professionals.
A study of certain personal details of adult Nigerian patients presenting for elective general surgery under anesthesia.
500 adult Nigerian patients presenting for elective general surgery under anesthesia were studied with regard to age, sex, obesity, smoking and drinking habits and associated medical diseases. The results showed equal sex distribution with 60% of the patients in the 21-40 years age group. About 30% of the patients (predominantly females) were obese. Smoking and drinking habits were relatively low especially in the females. About 25% of the patients have associated medical disorders of which hypertension and anemia were the commonest. Chronic obstructive lung disease and atherosclerotic heart disease were relatively uncommon. Multiple drug therapy was not a problem in this series.