1. www.acssurgery.com
WILEY W. SOUBA, MD, ScD, FACS, Editorial Chair DOUGLAS W. WILMORE, MD, FACS, Founding Editor July 2008
THE BEST THIS MONTH’S UPDATES
SURGICAL 2 Head and Neck the earlobe), and finally turns
downward to descend along the
THINKING 6 Parotidectomy
LEONARD R. HENRY, MD, AND JOHN A.
sternocleidomastoid muscle. Skin
flaps are then created to expose the
parotid gland. The posterior-inferior
The Fundamentals of RIDGE, MD, PHD, FACS skin flap is then elevated in a similar
manner.
Laparoscopic Surgery (FLS) National Naval Medical Center, Once the skin flaps have been
Program: Its Time Has Come! Uniformed Services University of the developed and retracted, the next
Health Sciences; Fox Chase Cancer step is to identify the facial nerve.
NATHANIEL J. SOPER, MD
Center, Temple University School of Usually, the nerve may be identified
Department of Surgery, Medicine either at its main trunk (the ante-
Northwestern University Feinberg DOI 10.2310/7800.S02C06 grade approach) or at one of the
School of Medicine distal branches, with subsequent
Most parotid tumors are benign, dissection back toward the main
DOI 10.2310/7800.2008.NCjul necessitating only superficial trunk (the retrograde approach). For
he incorporation of laparoscopic parotidectomy.
T surgery into the armamentarium he parotid gland, the largest of
a lateral parotidectomy, our
preference is to identify the main
of general surgeons occurred rapidly
in the early 1990s. There was a
T the salivary glands, occupies the
space immediately anterior to the
trunk first (unless it is thoroughly
obscured by tumor or scar), keeping
distinct “learning curve” during the ear, overlying the angle of the in mind that the nerve typically lies
uptake of laparoscopic cholecystec- mandible. The portion of the deeper than one might expect.
tomy, with an increase in bile duct parotid gland lateral to the facial Once identified, the plane of the
injuries.1 Much of the education nerve (about 80% of the gland) is facial nerve remains uniform
offered on laparoscopic techniques designated as the superficial lobe; throughout the gland (unless the
for established surgeons was the portion medial to the facial nerve is displaced by a tumor) and
provided by industry, and many nerve (the remaining 20%) is serves to guide the parenchymal
surgeons learned “one-handed” designated as the deep lobe. dissection, which proceeds directly
operating techniques, whereas the Deep lobe tumors often present over the facial nerve. We do not
underpinning cognitive aspects clinically as retromandibular or
continued on page 3
unique to laparoscopy were given parapharyngeal masses, with
short shrift. In the late 1990s, the displacement of the tonsil or the soft
Society of American Gastrointestinal
and Endoscopic Surgeons (SAGES)
palate appreciated in the throat. The
overwhelming majority of parotid In This Issue
began developing the Fundamentals tumors, however, are benign and
The Best Surgical Thinking
of Laparoscopic Surgery (FLS), a lateral to the facial nerve. This The Fundamentals of Laparoscopic
program designed to cover the chapter focuses primarily on Surgery (FLS) Program: Its Time Has
cognitive and psychomotor aspects superficial parotidectomy. Come! 1
unique to laparoscopic surgery, 2 Head and Neck
associated with a mechanism for Operative Technique for 6 Parotidectomy 1
assessment. It was not SAGES’ Parotidectomy 2 Head and Neck
he incision begins immediately 9 Thyroid and Parathyroid Operations 4
intent to develop a certifying
examination but rather to provide T anterior to the ear, continues
downward past the tragus, curves
4 Thorax
8 Minimally Invasive Esophageal
continued on page 2 back under the ear (staying close to Procedures 4
3. www.acssurgery.com What’s New in ACS Surgery 3
This Month’s CME
THIS MONTH’S UPDATES
continued from page 1 Chapters
regularly resect the entire lateral mandible and may reach a signifi- ACS Surgery offers CME in
lobe of the parotid gland unless the cant size in patients with large or convenient online format. As
tumor is large and such resection is recurrent tumors. Strictly speaking, many as 60 AMA PRA Category
required on oncologic grounds. this cosmetic change is a necessary 1 credits can be earned at
Complete superficial parotidec- feature of the procedure, not a any time during the year. The
tomy with full dissection of all facial complication. following chapters are available
nerve branches is seldom necessary, for CME credit this month:
although, in some cases, it is
mandated by tumor size or histo-
Outcome Evaluation of 2 Head and Neck
6 Parotidectomy
logic findings. The question of Parotidectomy
2 Head and Neck
whether to sacrifice the facial nerve ith proper surgical technique,
almost invariably arises in the
setting of malignancy. In our view,
W superficial or partial superficial
parotidectomy can be performed
9 Thyroid and Parathyroid Operations
4 Thorax
8 Minimally Invasive Esophageal
this measure is seldom necessary. safely and within a reasonable Procedures
Benign tumors tend to displace the operating time.
nerve, not invade it. Sacrifice of the
nerve probably does not enhance
survival.
Before closure, absolute hemosta-
sis is confirmed. Facial nerve
function is evaluated in the recovery
room, with particular attention paid
THE BEST SURGICAL THINKING
continued from page 2
to whether the patient is able to
close the eyelid. general surgery resident training surgery trainees, the FLS program
program in the United States and should achieve wide dissemination
Canada to obtain one of the FLS and improve the safety of patients
Complications of video training boxes as part of their undergoing laparoscopic surgery.
Parotidectomy Residency Review Committee-
mandated simulation effort. Fur-
tudies have found that transient References
S paralysis of all or part of the
facial nerve occurs in 17 to 100% of
thermore, vouchers for completing
the testing component of FLS will be 1. Strasberg SM, Hertl M, Soper
supplied for each graduating chief NJ. An analysis of the problem
patients undergoing parotidectomy, resident in general surgery and to of biliary injury during laparo-
depending on the extent of the fellows in gastrointestinal surgery scopic cholecystectomy. J Am
resection and the location of the fellowships. Notices have gone out Coll Surg 1995;180:101–25.
tumor. Fortunately, permanent to all program directors informing 2. Peters JH, Fried GM, Swanstrom
paralysis is uncommon, occurring in them of the ability to obtain these LL, et al. Development and
fewer than 5% of cases. The resources. It thus seems likely that validation of a comprehensive
primary complications are gustatory FLS will be incorporated in virtually program of education and
sweating, sialocele, and cosmetic all North American training assessment of the basic funda-
changes. programs. mentals of laparoscopic surgery.
Gustatory sweating, or Frey In summary, the FLS program was Surgery 2004;135:21–7.
syndrome, occurs in most patients developed because of an identified 3. Swanstrom LL, Fried GM,
after parotidectomy; it has been seen need to educate surgeons in the Hoffman KI, Soper NJ. Beta test
after submandibular gland resection underlying principles and basic skills results of a new system assessing
of laparoscopic surgery and because competence in laparoscopic
as well. The symptom complex
of the growing demand to document surgery. J Am Coll Surg
includes sweating, skin warmth, and
competency in surgical practice. The 2006;202:62–9.
flushing after chewing food and is 4. Derossis AM, Fried GM, Abra-
program has been extensively vetted
caused by cross-innervation of the by experts and validated in beta hamowicz M, et al. Development
parasympathetic and sympathetic testing. The inclusion of a testing of a model for training and
fibers supplying the parotid gland component ensures that competency evaluation of laparoscopic skills.
and the overlying skin. Sialocele, or in laparoscopy is both taught and Am J Surg 1998;15:482–7.
salivary fistula, has been reported evaluated. Given the partnership 5. Fried GM, Feldman LS, Vassiliou
to occur after 1 to 15% of paroti- with the ACS, the growing recogni- MC, et al. Proving the value of
dectomies. Parotidectomy creates a tion of FLS internationally, and the simulation in laparoscopic
hollow anterior and inferior to the recent Covidien grant allowing surgery. Ann Surg
ear, which may extend behind the widespread adoption by general 2004;240:518–28.
4. 4 What’s New in ACS Surgery • July 2008 www.acssurgery.com
THIS MONTH’S UPDATES
continued from page 3
2 Head and Neck mobilization of the lower thyroid Complications of
pole. The carotid sheath is retracted
laterally, and the thyroid gland is Thyroidectomy
9 Thyroid and Parathyroid he most significant complications
Operations
retracted anteriorly and medially.
This retraction puts tension on the
inferior thyroid artery and conse-
T of thyroidectomy are injury to the
recurrent laryngeal nerve, hypopara-
WEN T. SHEN, MD, GREGG H. JOSSART, quently on the recurrent laryngeal thyroidism, bleeding, injury to the
MD, FACS, AND ORLO H. CLARK, MD, nerve, thereby facilitating identifica- external branch of the superior
FACS tion of the nerve. The right and left laryngeal nerve, infection, seroma,
University of California, San recurrent laryngeal nerves must be or keloid.
Francisco; California Pacific Medical preserved during every thyroid
Center, San Francisco; University of operation. In identifying the
recurrent laryngeal nerves, it is Parathyroidectomy
California, San Francisco
he preparation for
DOI 10.2310/7800.S02C09
helpful to remember that they are
supplied by a small vascular plexus
and that a tiny vasa nervorum runs
T parathyroidectomy is similar to
that for thyroidectomy. The gold
The operative techniques for
parallel to and directly on each standard operation for primary
thyroidectomy and parathyroidec-
nerve. hyperparathyroidism remains bilateral
tomy are similar, and avoiding The pyramidal lobe (found in about neck exploration; however, the
injury of the laryngeal nerves is 80% of patients) is mobilized by excellent results of preoperative
paramount. retracting it caudally and by dissect- imaging with sestamibi scanning and
ing immediately adjacent to it in a ultrasonography, coupled with the
Operative Technique for cephalad direction. Once the availability of rapid intraoperative
parathyroid glands have been
Thyroidectomy carefully swept or dissected from the
parathyroid hormone assays, have
efore thyroidectomy, laryngoscopy made unilateral focused exploration
B is essential to determine whether
the vocal cords are functioning
thyroid gland and the recurrent
nerve has been identified, the
thyroid lobe can be quickly resected.
feasible for well-localized parathyroid
adenomas. The complications of
normally. Thereafter, as a rule, parathyroidectomy are similar to
dissection should always begin on those of thyroidectomy but occur
Special Concerns of less often.
the side of the suspected tumor; if
there is a problem with the dissec- Thyroidectomy
tion on this side, a less than total n rare occasions, thyroid or
thyroidectomy can be performed on
the contralateral side to prevent
O parathyroid cancers may invade
the trachea or the esophagus. As
4 Thorax
complications. The thyroid gland is much as 5 cm of the trachea can be 8 Minimally Invasive
exposed via a midline incision resected safely without impairment Esophageal Procedures
through the superficial layer of deep of the patient’s voice. If the invasion
cervical fascia between the strap is not extensive and is confined to FRANCESCO PALAZZO, MD, PIERO M.
muscles. However, if they are the anterior portion of the trachea, a FISICHELLA, MD, AND MARCO G. PATTI,
adherent to the underlying thyroid small section of the trachea that MD, FACS
tumor, the portion of the muscle contains the tumor should be
adhering to the tumor should be excised, and a tracheostomy may be University of California, San
sacrificed and removed en bloc with placed at the site of resection. Francisco; Loyola University
the specimen. Lymph nodes in the central neck Medical Center, Chicago; University
When a thyroid lobectomy is (medial to the carotid sheath) are
performed, the isthmus of the frequently involved in patients with continued on page 5
thyroid gland is usually divided papillary, medullary, and Hürthle
lateral to the midline, taking care
not to cut across the tumor. Once
cell cancer. These nodes should be
removed without injury to the Coming in August
the isthmus has been divided, parathyroid glands or the recurrent Elements of Contemporary Practice
dissection is continued superiorly, laryngeal nerves. A median sternoto- 8 Health Care Economics:
laterally, and posteriorly. It is my is rarely necessary for removal of The Broader Context
essential to avoid injuring the the thyroid gland, but if one proves
1 Basic Surgical and Perioperative
external branch of the superior necessary, the sternum should be Considerations
laryngeal nerve (responsible for divided to the level of the third 9 Ambulatory and Fast-Track Surgery
tensing the vocal cords). intercostal space and then laterally
8 Critical Care
The lower parathyroid gland is on one side at the space between the 22 Nutritional Support
usually encountered during lateral third and fourth ribs.
5. www.acssurgery.com What’s New in ACS Surgery 5
of Chicago Pritzker School of fundoplication as for Nissen generally comparable to those
Medicine fundoplication, and many of the obtained with corresponding open
surgical steps are the same. Over the surgical procedures. Delayed
DOI 10.2310/7800.S04C08
years, however, it has become esophageal leakage is a common
Treating benign esophageal evident that a partial fundoplication postoperative complication.
disorders with minimally invasive is not as durable as a total fundopli-
laparoscopic procedures yields cation. As a result, total fundoplica-
results comparable to those of
Reoperation for GERD
tion is currently considered the urrently, an increasing number of
treatment with traditional
operations.
procedure of choice for patients
with GERD, regardless of the
C patients are being seen for
evaluation and treatment of foregut
he development of laparoscopic strength of their esophageal
T surgery over the past 20 years has
caused a significant shift in the
peristalsis.
symptoms after laparoscopic
antireflux surgery. If the symptoms
persist or heartburn and regurgita-
treatment of benign esophageal Laparoscopic Heller tion occur, a thorough evaluation
diseases. Consequently, minimally (with barium swallow, endoscopy,
invasive surgery is increasingly Myotomy with Partial esophageal manometry, and pH
considered first-line treatment for Fundoplication monitoring) is carried out.
achalasia, and laparoscopic fundopli- oday, laparoscopic Heller We do not routinely attempt a
cation is considered more readily and
at an earlier stage to manage gastro-
T myotomy with partial fundoplica-
tion has supplanted left thoraco-
second antireflux operation laparo-
scopically, and the optimal proce-
esophageal reflux disease (GERD). scopic myotomy as the procedure of dure depends on the original
Here we focus on the operative choice for esophageal achalasia. approach (open versus laparoscop-
procedures for the most common Candidates should undergo a ic), the severity of the adhesions,
minimally invasive approaches. and the specific technique used for
thorough and careful evaluation to
establish the diagnosis and charac- the first operation (total or partial
Laparoscopic Nissen terize the disease. Many of the steps fundoplication). Because the risk of
gastric or esophageal perforation or
Fundoplication in a laparoscopic Heller myotomy
damage to the vagus nerves is much
ll candidates for laparoscopic are the same as the corresponding
A fundoplication should undergo
(1) symptomatic evaluation, with
steps in a laparoscopic fundoplica-
tion; intraoperative endoscopy is
higher during a second antireflux
operation, the surgeon must proceed
with extreme care, making sure to
symptoms graded with respect to where the operative technique
identify structures completely before
their intensity both before and after differs, and great care must be taken
dividing them. The success rate falls
the operation; (2) an upper gastroin- not to perforate the esophagus. The
to 70 to 80% for a second such
testinal series, to diagnose an results obtained to date with operation.
existing hiatal hernia; (3) endos- laparoscopic Heller myotomy and
copy, to confirm a symptom-based partial fundoplication are excellent
diagnosis of GERD; (4) esophageal and are generally comparable Reoperation for Esophageal
manometry, which provides useful to those obtained with the Achalasia
information about the motor corresponding open surgical aparoscopic Heller myotomy
function of the esophagus; and (5)
ambulatory pH monitoring, the
procedure. L improves swallowing in more
than 90% of patients. What causes
most reliable test for the diagnosis Left Thoracoscopic the relatively few failures reported is
of GERD. Once the operation is still incompletely understood.
complete, the greatest complication
Myotomy Typically, a failed Heller myotomy
urrently, we consider a left
is esophageal or gastric perforation.
Optimal management consists of C thoracoscopic myotomy for
patients in whom multiple previous
is signaled either by persistent
dysphagia or by recurrent dysphagia
laparotomy and direct repair. that develops after a variable
abdominal procedures (done to treat symptom-free interval following the
other diseases) would preclude a original operation. There are two
Laparoscopic Partial laparoscopic approach. Preoperative treatment options for persistent or
(Guarner) Fundoplication evaluation is essentially the same recurrent dysphagia after Heller
reoperative evaluation and as that for laparoscopic Heller
P operative planning are essentially
the same for partial (Guarner)
myotomy. The results obtained
with thoracoscopic myotomy are
myotomy: pneumatic dilatation and
a second operation tailored to the
results of preoperative evaluation.
