CONVENTION ISSUE:
American College of Surgeons Clinical Congress
GENERALSURGERYNEWS.COM
October 2013 • Volume 40 • Number 10
The Independent Monthly Newspaper for the General Surgeon
®
Opinion
Surfing the Bore Tide
Better Patient Care Requires a New Way of Thinking
B Y L AUREN K OSINSKI , MD
How ‘Complexity Science’ Can Be Used To Improve Health Care And Provide Better Value to Our Patients
W
hen I lived in Alaska, everyone knew someone who had died, whether seasoned outdoorsman or novice. Extreme weather, solitude and the wilderness are part of the allure of Alaska, but even small mistakes can have big consequences there. Exposure. Capsized boats. Floatplane crashes. Lost footing on a trail. Animal encounters. Even bad divorces. But some stories grip the imagination and are told over and over again. One such apocryphal tale is of an obese woman fishing alone in her boat who cast anchor before turning in for the night but misgauged the bay’s depth and the speed of the incoming tide. As the tide rushed in, the anchored end of the boat tilted, icecold sea water rushed over the deck and the cabin door at the aft end submerged before she awakened to discover the crisis. By then, the cabin door could not be opened, and she was too large to escape through a cabin window. Her plight is haunting: trapped not just in her boat but in her body, waiting to die as minutes filled hours, hoping for hypothermia see BORE TIDE page 35
B Y B RUCE R AMSHAW , MD feew months ago, I was in Gdansk, Poland, foor the annual meeting of the European H Hernia Society. In a session on guidelines, Dr. JJaap Bonjer presented a paper that looked at exxpert consensus regarding guidelines published by the International Endo Hernia Soociety. Guidelines were presented based on levels of evidence, with Level 1 evidence being the highest quality and Level 5 being the lowest. Interestingly in this revview, Level 5 guidelines were evaluated as appropriate by experts about 85% of the tim me (a solid B grade), but amazingly, Level 1 gguidelines were judged as appropriate only aboout 60% of the time, a near-failing grade. see COMPLEXITY SCIENCE page 38
Surgical Entrepreneurism An Interview With the Inventor of the Bookwalter Retractor BY PETER KIM, MD
No act of kindness, however small, is wasted. —Aesop, 600 BC
PROCEDURAL BREAKTHROUGH ®
Case-Based Report on XCM BIOLOGIC Tissue Matrix for Ventral Hernia Repair
see page 12
W
hen surgeons need to convert from a laparoscopic case to open abdominal surgery, they often shout, “Get the Bookwalter!” The
INSIDE In the News
Surgeons’ Lounge
Stitches
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10
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Expert Pro/Con Debate on the Treatment of Colorectal Liver Metastases: Yes or No on Chemotherapy?
A Patient With a Grade IV Splenic Laceration
Landmark Strides in Laparoscopic Technologies
Bookwalter retractor is the most popular retractor system for holding open abdominal incisions. The man who invented and promotes the retractor system is John Bookwalter, MD, and I had the good fortune to sit next to him by chance at a dinner meeting of the New York see BOOKWALTER page 32
Protocol Promises Better Surgical Recovery B Y M ICHAEL V LESSIDES SAN DIEGO—Programs that promote enhanced recovery after surgery are beneficial for both patients and institutions, according to a recent study that supports the use of the increasingly common treatment plans. Popularized in Europe, so-called ERAS programs are becoming more widespread in the United States, although the data for their overall efficacy here are still lacking. The latest study should help. North Carolina researchers found that surgical patients undergoing the novel program had significantly reduced lengths of stay and 30-day readmission rates, as well as potentially lower hospital costs, than those who received conventional care. “Enhanced recovery after surgery is a concept that integrates a number of evidence-based practices into protocolized care, in this case into colorectal surgery patients,” said Tong Joo (T.J.) Gan, MD, vice chair of anesthesiology at Duke University, in Durham, N.C., who led the work. Dr. Gan and his colleagues studied 236 see ERAS page 42
REPORT Ventral Hernia Repair: State of the Art, Current Challenges, and Future Directions See insert at page 22