Essential Articles for Surgical Residents (2022-2023)

Featured

We are excited to share a new section titled “Essential Articles for Surgical Residents.”

Keeping up with surgical literature in residency can be challenging. This list was created to serve as an easily accessible, up-to-date, and evidence-based resource for residents.

The content has been curated by faculty from each department and is intended to supplement the standard educational curriculum of each rotation with current and relevant literature.

Continue reading

The risk of injury to inferior epigastric artery (IEA) subjects during abdominal procedure

“The anatomical position of the inferior epigastric artery (IEA) subjects it to risk of injury during abdominal procedures that are close to the artery, such as laparoscopic trocar insertion, insertion of intra-abdominal drains, Tenckhoffâ catheter (peritoneal dialysis catheter) and paracentesis. This article aims to raise the awareness of the anatomical variations of the course of the IEA in relation to abdominal landmarks in order to define a safer zone for laparoscopic ancillary trocar placement. Methods of managing the IEA injury as well as techniques to minimise the risk of injury to the IEA are reviewed and discussed.”

Conclusion: The best preventative measure to avoid ancillary trocar injury to the IEA is inserting the trocar after identifying the IEA with direct laparoscopic visualisation. It is a good
practice to inspect all ancillary trocar sites for signs of IEA injury before the laparoscope is finally withdrawn. Tamponade, suturing, trans-catheter arterial embolisation and ultrasound-guided thrombin injection have been shown to arrest bleeding effectively.”

(Wong)

Wong C, et al Inferior epigastric artery: Surface anatomy, prevention and management of injury. Aust N Z J Obstet Gynaecol. 2016 Apr;56(2):137-41.

PREOPERATIVE URETERAL STENT PLACEMENT IN THE IDENTIFICATION OF INTRAOPERATIVE IDENTIFICATION OF IATROGENIC URETERAL INJURY?

“The use of prophylactic ureteral stents remains controversial and could help in the intraoperative identification of ureteral injury.”

Methods:
Patients undergoing elective abdominal colorectal surgery and preoperative ureteral stent placement at three enterprise-wide tertiary referral hospitals between 2015 and 2021 were retrospectively identified through their billing records. The main study endpoint was ureteral injury identified within 30 days postoperatively. The decision to place ureteral stents was at the discretion of the treating surgeon. A number of demographic, disease-related, and treatment-related variables were examined for possible association with ureteral stent placement. We compared the incidence of ureteral injury and timing of the identification according to use of ureteral stents. Bivariate associations were examined using Kruskal-Wallis tests for continuous variables and Chi-square tests for categorical variables.

Results:
Out of 7925 patients undergoing elective colorectal surgery, 1118 (16.3%) underwent preoperative ureteral stent placement. Use of preoperative ureteral stents was significantly associated with a higher ASA class (53% vs 44% ASA3, p= <0.001), wound classification (28% vs 18% Type III; 15.6% vs 4.8% Type IV, p <0.001), and longer duration of surgery (5.6 vs 3.7 hours, p <0.001). With respect to postoperative complications, use of ureteral stents was associated with significantly increased risk of iatrogenic ureteral injury (1.3% vs 0.2%, p= <0.001), acute kidney injury (14% vs 9%, p<0.001), and UTI (7% vs 3%, p<0.001). Ureteral injury was identified in 32 patients (0.4%). Of these, 15 did not have a stent, and 17 had preoperative stent placement. The ureteral injury was identified intraoperatively in 19/32 (59%) patients. However, use of ureteral stents was not associated with increased intraoperative identification (53% vs 47%, p= 0.43).

Heimberger, Mark, et al. “925: CAN PREOPERATIVE URETERAL STENT PLACEMENT HELP IN THE INTRAOPERATIVE IDENTIFICATION OF IATROGENIC URETERAL INJURY?.” Gastroenterology 162.7 (2022): S-1348. Free Full Text

Incidence of biliary stricture formation after pancreaticoduodenectomy (PD) for benign and malignant periampullary disease.

“Between January 1995 and April 2003, 1595 patients underwent PD for periampullary disease (392 benign, 1203 malignant). A retrospective analysis of a prospectively collected database was performed to determine the incidence of biliary stricture after PD.”

Results: “Forty-two of the 1595 patients (2.6%) who underwent PD developed postoperative jaundice secondary to a stricture of the biliary-enteric anastomosis. There was no difference in the incidence of biliary strictures after resection for benign (n = 10, 2.6%) or malignant disease (n = 32, 2.6%). The median time to stricture formation resulting in jaundice was 13 months (range, 1–106 months) and was similar for patients with benign and malignant disease. Preoperative jaundice did not protect against biliary stricture formation. By univariate analysis, biliary strictures were associated with preoperative percutaneous biliary drainage (odds ratio [OR] = 2.11, P = 0.02) and postoperative biliary stenting (OR = 2.11, P = 0.013). Postoperative chemoradiotherapy in patients with malignant disease was not associated with stricture formation. All strictures were initially managed with percutaneous biliary balloon dilatation and stenting, and only 2 patients required redo hepaticojejunostomy. Recurrent neoplastic disease was discovered in only 3 of the 32 patients (9%) with malignant disease. All 3 of these patients had cholangiocarcinoma as their initial diagnosis.”

(House)

House MG, et al Incidence and outcome of biliary strictures after pancreaticoduodenectomy. Ann Surg. 2006 May;243(5):571-6; discussion 576-8 Free Full Text

Iatrogenic urologic injuries 

Ferrara M, Kann BR. Urological injuries during colorectal surgery. Clin Colon Rectal Surg. 2019 May;32(3):196-203.

“A recent retrospective population-based study of patients in the United States undergoing colorectal surgery found the overall incidence of ureteral injury to be 0.28%. The incidence was found to be significantly higher in patients with stage 3 or 4 cancer, malnutrition, steroid use, and in operations done at teaching hospitals. Rectal cancer cases were found to have the highest rates of ureteral injuries (7.1/1,000), followed by Crohn’s disease and diverticular disease (2.9/1,000 each). In this review, laparoscopic surgery was associated with a lower incidence of ureteral injuries when compared with open (1.1 vs. 2.8/1,000, p  < 0.001). Of the specific operations reviewed, abdominoperineal resection (APR) was found to have the highest rate of ureteral injury at 7.1/1,000 cases.” (Ferrara, 2019, p. 196)

Continue reading

Resource Highlight: Surgical Anatomy Apps for Liver, Lung, and Male Pelvis

These were created by Emory University and are available for Apple devices.

Download here.

Surgical Anatomy of the Liver

“This app is for trainees, medical students, instructors, and anyone that needs a quick way to learn or teach liver anatomy.This hands-on tool allows you to mentally map the 3D anatomy of the liver in a way that was never possible with illustrations or imaging studies.

Emory Surgical Oncologist Shishir Maithel, MD, FACS, guided a certified medical illustrator in the process of digitally sculpting the anatomy to be both clear and accurate. The anatomy is a synthesis of radiographic, cadaveric, and surgical references, as well as hundreds of hours of liver surgery.”

Continue reading

Surgical treatment and risk of recurrence of horseshoe anorectal abscess

Gaertner WB, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum. 2022 Aug 1;65(8):964-985. Full-text for Emory users.

Patients with acute anorectal abscess should be treated promptly with incision and drainage. Grade of recommendation: strong recommendation based on low-quality evidence, 1C.

“Abscesses that cross the midline (ie, horseshoe) can be challenging to manage. These abscesses most often involve the deep postanal space and extend laterally into the ischiorectal spaces. [40,71] Under these circumstances, primary lay-open fistulotomy should typically be avoided because these fistulas tend to be transsphincteric. The Hanley procedure, a technique that drains the deep postanal space and uses counter incisions to address the ischiorectal spaces, is effective in the setting of a horseshoe abscess, [71] although it may negatively impact anal sphincter function. [40,71] A modified Hanley technique using a posterior midline partial sphincterotomy to unroof the postanal space plus seton placement has a high rate of abscess resolution and has been reported to better preserve anorectal function compared to other operative interventions. [40,72,73]” (p. 969)

“After drainage, abscesses may recur in up to 44% of patients, most often within 1 year of initial treatment. [2,10,70] Inadequate drainage, the presence of loculations or a horseshoe-type abscess, and not performing a primary fistulotomy are risk factors for recurrent abscess (primary fistulotomy is further addressed in recommendation no. 4). [10,71,72]” (p. 969)

Continue reading