Category Archives: General surgery

cirugia general

More about Single incision laparoscopic surgery (SILS)

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Since we’ve talked about single incision laparoscopic surgery (SILS) here at Bogotá Surgery after interviewing several of the surgeons performing this surgical technique in Bogotá, Colombia – I wanted to bring readers more information about the technique itself.

I have added some links to published articles discussing this technique and how it can be used as treatment for different surgical conditions. (all case reports are from 2011.)  This is just a limited selection – there are hundreds of articles on this technique, and it is now being for a wide variety of abdominal conditions.

Case report from Japan – treatment of giant liver cyst (with color photos and radiographic information.)

Single port laparoscopy for adnexal surgery – 22 cases:  this study has a photo that demonstrates the sterile glove technique that I’ve mentioned previously (that allows for a smaller peri-umbilical incision than when using a commercial instrument holder.)

an Indian study discussing this technique for kidney donors (for organ harvesting) – has a nice post-operative photo of kidney donor.

Note: while this Turkish study is descriptive and colorful – it’s not true single incision laparoscopic surgery – as observed in Bogotá, Colombia and other facilities.  (It’s only single incision surgery if there’s just one incision..)

Single incision laparoscopy revisited

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A new abstract published [ and re-posted below] in advance of the article – confirms what Bogotá surgeons already know –

Uniport or single incision laparoscopy is a safe, effective surgical treatment which reduces post-operative pain, length of stay and recovery time for patients while providing better cosmetic outcomes.

Surprising to me, it seems there is still hesitation among surgeons in the United States to adopt this technique for routine procedures such as appendectomy, or cholecystectomy.  In fact, during a recent multi-day tour of Duke University – I was unable to find out information/ or confirm the use of this technique by a single surgeon in the facility.  [My methods were by no means definitive or scientific – I questioned surgeons and anesthesiologists but it’s possible that surgeons using this technique were not identified.  However, the majority of people I spoke to didn’t know what SIL was, and required a description of the procedure, which adds to my suspicions that this procedure is not being performed at Duke.   I will be back at Duke later this month, and will continue to investigate.]  if true, this is a significant finding, and failure in American surgery – Duke is one of the leaders in surgical innovation and emerging therapies.

Now the abtract below talks about increased surgical time – which is true, initially as surgeons learn the technique.  However, as surgeons become more experienced in this procedure, this is no longer the case. In the cases I observed in Colombia, there was no increase in surgery time – but the surgeon has been performing this technique for several years.

Correction:  Despite what I was initially informed – Duke general surgeons do use SILS, and use the single incision laparoscopy approach as part of their living donor kidney transplantation.    I apologize for the error. 

Abstract re-posted below:

 Single incision laparoscopic cholecystectomy (SILC) versus laparoscopic cholecystectomy (LC) – a matched pair analysis

Source

Department of Surgery, Krankenhaus der Elisabethinen, Fadingerstrasse 1, 4020, Linz, Austria, odogangl@yahoo.com.

Abstract

INTRODUCTION:

The aim of our study was to compare single incision laparoscopic cholecystectomy (SILC) and laparoscopic cholecystectomy (LC) with respect to complications, operating time, postoperative pain, use of analgesics, length of stay, return to work, rate of incisional hernia, and cosmetic outcome.

METHODS:

Sixty-seven patients underwent SILC. Of a cohort of 163 LC operated in the same time period, 67 patients were chosen for a matched pair analysis. Pairs were matched for age, gender, ASA, BMI, acuity, and previous abdominal surgery. In the SILC group, patient characteristics (gender, age, BMI, comorbidities, ASA, previous abdominal surgery, symptomatic cholecystolithiasis, cholecystitis) and perioperative data (surgeon, operation time, conversion rate and cause, intraoperative complications, postoperative complications, reoperation rate, VAS at 24 h, VAS at 48 h, use of analgesics according to WHO class, and length of stay) were collected prospectively.

RESULTS:

Follow-up in the SILC and LC group was completed with a minimum of 17 and a maximum of 26 months; data acquired were recovery time the patients needed until they were able to get back into the working process, long-term incidence of postoperative hernias, and satisfaction with cosmetic outcome. Operating time was longer for SILC (median 75 min, range 39-168 vs. 63, range 23-164, p = 0.039). There were no significant differences for SILC and LC with regard to postoperative pain measured by VAS at 24 h (median 3, range 0-8 vs. 2, range 0-8, p = 0.224), at 48 h (median 2, range 0-6 vs. 2, range 0-8, p = 0.571), use of analgesics, and length of stay (median 2 days, range 1-9 vs. 2, range 1-11, p = 0.098). There was no major complication in either group. The completion rate of SILC was 85.1% (57 of 67). Although there was a trend towards an earlier return to the working process in patients of the SILC group, this was not significant. The rate of incisional hernias was 1.9% (1/53) in the SILC and 2.1% (1/48) in the LC group indicating no significant difference. Self-assessment of satisfaction with the cosmetic outcome was not judged different by patients in both groups.

CONCLUSION:

SILC is associated with longer operating time, but equals LC with respect to safety, postoperative pain, use of analgesics, length of stay, return to work, rate of incisional hernia, and cosmetic outcome.

Langenbecks Arch Surg. 2011 Jun 22. [Epub ahead of print]

Bogota Surgery and the International Medical Travel Journal

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Thanks to the eagle-eyed reader who notified me that portions of one of my articles “Bogotá hospital offers hope to abdominal cancer patients” (originally published on Colombia Reports.com) was featured in the article, “Agencies promote Central and Southern American medical tourism.”

I’ve asked them to provide a link to the original article so readers can get more information on the topic.

Update: 29 June 2011: Here’s a link to the new article on Treatment Abroad (which is an International Medical Travel Journal sister site) that gives their readers the information they really need. (The name of the doctor, of course!)  It’s a summary of the original Colombia Reports.com article. They still haven’t cited the ‘borrowed’ content on the original article, or provided the name of the physician doing the treatment (Dr. Fernando Arias) but I guess it’s an improvement.

The Future is Now – HIPEC in the news again..

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Another article on the effectiveness of HIPEC (cytoreductive surgery with intraoperative hyperthermic chemotherapy) in the news.  This story comes out of India and highlights doctors there and the HIPEC procedure for treatment of abdominal cancers (intestinal and ovarian cancers.)

The Future is Now..  in an article on Medscape, dated December of 2010 and originally published in Future Oncology, Dr. Ze Lu et. al discusses the future of cancer treatment.  (The article is several pages in length – so I haven’t re-posted but reference information is provided below).  Dr. Ze Lu and his colleagues believe the future of oncology treatment is…. Intraperitoneal Hyperthermic Chemotherapy (HIPEC)..

In August, we’ll check back in with Bogotá’s resident expert on HIPEC, Dr. Fernando Arias.

Reference:

Lu, Z., Wang, J.,  Wientjes, G., & Au, J. (2010).  Intraperitoneal therapy for peritoneal cancer.  Future Oncology. 2010 (6) 10; 1625 -1641

Bogota surgeons stay ahead of the curve

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As we’ve seen several times before, Bogotá surgeons stay ahead of the curve on cutting edge treatments.  In the last several weeks, HIPEC or Hyperthermic intraperitoneal chemotherapy (Sugarbaker procedure) has been dotting the news headlines in the United States, and across the globe.

But as my readers here at Bogotá Surgery know, not only have we talked about HIPEC in the past – Dr. Arias has been performing this procedure at Fundacion Santa Fe de Bogota since 2009.  He reports he did eight cases in May alone.  (This is considered fairly high volume if you review the amount of cases being done at other centers.)

Planning to catch up with Dr. Arias and check in later this summer..

Interview with Dr. Borraez, Bogota Bag: 27 years later

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One of my new articles on Dr. Borraez has been published to Yahoo! (associated content section) – it’s shared content with the site..  I’ve also written two other articles, one of original content, so I’ll let you know if they get published.  I thought it might get a little more exposure this way.  I’ve written this trio of articles for Yahoo! as a trial run, so we’ll see how it goes..

Note:  Due to recent changes at Yahoo! this article link has changed.  I have updated the link to the new article link. Please let me know if you have difficulty accessing this article.

Dr. Oswaldo Borraez, Trauma Surgeon

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Most of you will never meet Dr. Borraez, a trauma surgeon at hospital San Blas, one of the public hospitals in the poorest neighborhood in Bogota, but now you will have heard about him.  In March of 1984, when he was a second year surgical resident Dr. Borraez , training at San Juan de Dios, Dr. Borraez was assisting in a surgical case with a patient that had a serious infection preventing closure of the abdomen.

Dr. Oswaldo Borraez, Trauma Surgeon, The Bogota Bag

(In cases of severe abdominal trauma, infection or necrosis closure of the abdomen can lead to the patient’s death due to compression of the abdominal compartment – leading to a sequelae of abdominal compartment syndrome —> internal organ hypoperfusion —-> organ failure  —-> respiratory distress —> death.  So basically all the swollen abdominal organs crush the blood vessels and other structures..)

During this case, the attending surgeon and the other operating room staff were looking for something to use to close the abdomen*.  Sometimes surgeons used sterile operating room towels but that increased infection and allowed for massive fluid losses, and the synthetic films were prohibitively expensive (and not without their own problems.)

So while he was in the OR, Dr. Borraez spies the IV bag, and starts thinking.. He then took the largest bag made (a urology fluid bag – 3 liters) sterilized it, and placed it in the abdomen.  And it worked – perfectly, as if it had been designed for that purpose..  It was clear, which allowed surgeons to monitor the wound, it was hypoallergenic, it prevented infection, it’s strong yet flexible and most of all – it was cheap (about 2 dollars) and available in any hospital – world-wide.

Since then, he has been recognized internationally for its use, especially after noted Atlanta trauma surgeon, Dr. David Feliciano came to Bogotá and saw this technique in use.  He wrote about it in standard American trauma textbooks used worldwide, gaining some well deserved recognition for this kind Bogotá physician, who continues to work and innovate (for the last 27 years) in this humble hospital serving Bogotá’s neediest patients.

He now speaks at conferences world-wide, talking about the Bogotá bag – and different ways it is now being used.  Hundreds of research studies and case reports have confirmed his findings.  His contribution was recognized as one of Colombia’s top ten innovations in Medicine, along with the Hakim valve (which we mentioned in another post.)

He has successfully used the Bogotá bag as a permanently implanted internal closure device (placed between the muscle and the intestines) in 55 patients with no problems.

He continues to innovate for more affordable and practical wound closure devices.  Currently, he has adapted a colostomy bag, along with a natural sponge and a suction canister as an effective wound-vacuum closure device, which mimics the success of the cost-prohibitive ‘wound vac’ (KCI) but only costs about a dollar to implement.  (Wound vacs can be several hundred dollars per day of use.)

Yet, somehow, in between seeing patients, surgery, creating affordable solutions and teaching residents – he found time to sit down, explain all of this to me – and show me several patients with their “Borraez bag” in place.

* a temporary measure until swelling / infection subsides and allows for surgical closure.

In other news, I want to say hello to one of ‘my patients’ – (I know he is reading this) Cristian, a very nice thoracic surgery patient that I met during rounds one day.  I tried to take a picture (he was very gracious and granted permission instantly) to show what a great guy he was – I met him as he was walking down the hall, chest tube canister in one hand,  and puffing on his incentive spirometer in the other.)

He, too, made time for me, a strange American nurse, speaking bad Spanish – to answer my questions and tell me all about why he was walking the halls and puffing on this little box.. He gave me a tour of the hospital while we walked, and he puffed intermittently, as I thought about how everyone, doctors, nurses and patients have been so welcoming to me here.  This kindness has certainly made this project not only possible, but a wonderful experience, that I will greatly miss when I return to the USA in a few days.

The Future of Thoracic Surgery

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Dr. Juan Carlos Varon in the bronchoscopy suite


Actually, this title sounds way too dire for the pleasant and relaxed day I spent over at Hospital Santa Clara, interviewing Dr. Barrios, Thoracic Surgeon and two Thoracic residents, Dr. Juan Carlos Veron and Dr. Carlos Carvajal.. But it’s essentially true as I talked to the up and coming Dr. Barrios, and the future thoracic surgeons… Dr. Barrios is currently involved in some very interesting treatments for metastatic cancer.

Dr. Juan Carlos Varon, unmasked

Dr. Carlos Carvajal

I also interviewed Dr. Juan Manuel Troncoso and his partner, Dr. Elena Facundo, two general surgeons who are currently involved in some interesting projects..

Dr. Fabian Emura, of the EmuraCenter

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Dr. Fabian Emura, of the EmuraCenter

is a gastroenterologist and general surgeon here in Bogota, who specializes in the detection and treatment of digestive cancers.  Along with his clinic, he has also created two separate divisions; a foundation for promote the prevention and detection of digestive cancers, and a medical education division – which supports training physicians world-wide in the endoscopy techniques he currently uses.

Currently, Dr. Emura is the only physician outside of China, Korea and Japan (where gastric cancer is endemic, and accounts for 20% of all cancers) who is treating early stage (stage I) cancers with endoscopic surgery versus a more radical gastrectomy.  This procedure has already been well validated in Asia, where it has been used for over a decade.

Dr. Emura has also created and implemented a classification system for the grading and staging of digestive lesions.

By using chromography endoscopy (or chromoendoscopy) and a wax dye,  doctors such as Dr. Emura are better able to visualize lesions that might otherwise be missed.

His research has also focused on differentiating colon lesions endoscopically, (to prevent unnecessary surgery for benign lesions).

He is currently working on screening guidelines (particularly for populations with higher incidence of gastric cancers such as in Colombia) because one of the main problems that still exists – is that the majority of patients with stomach cancer – are diagnosed late – when treatment options are limited and noncurative.

The Doctors Luna at Clinica Shaio

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Interviewed the father and son, Dr. Ruben Francisco Luna Romero and Dr. Ruben Daniel Luna Alvaro this morning, before following Dr. Luna (Alvaro) to the operating room. Dr. Luna was joined by the remaining doctor in the Grammo practice, Dr. Cesar Guevara.

Due to some technical issues – i will post photos later.

Update: 21 April 2011: Photos

Dr. Luna, general and transplant surgeon

Dr. Guevara (left) and Dr. Luna (right) during laparoscopic surgery

Dr. Cesar Guevara, Grammo

In the OR with Dr. Buitrago, in the dentist’s chair and more

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Spent the morning at Shaio, in the operating room with Dr. Ricardo Buitrago.. Either my gringa accent is improving (doubtful) or I really have become a familiar face around there..  Observed Dr. Buitrago perform a couple of cases; the second was a VATS thymectomy, which definitely ranks above the traditional sternotomy.

Dr. Buitrago, thoracic surgeon

Ran into some strangely reticent native english speakers in the halls of Shaio today.. (Usually Americans, Brits and the like get real familiar with each other when we see another..) Didn’t introduce themselves even after I made a point of introducing myself.. Something’s up over at Clinica Shaio.. Is it a medical tourism company, or an impending branding agreement?  I’ll see what I can find out.

Next I checked in with Dr. Gamboa, DDS – for those of you reading from afar – dental evaluations are completely different – they require an actual patient visit (no observation here.)  Now that all of my family, friends, classmates and housemates have served as confederates for dental visits – I knew what was next when I cracked a tooth last week.. (Just so everyone knows how dedicated I am to my research – I had several dental repairs without anesthesia of any sort.. (no local, nada).   And truthfully, it went very well.. (and my teeth look / feel great..)

Dr. Gamboa, DDS

last, but certainly not least for today was Dr. Fabian Emura, MD, PhD.  He didn’t have a lot of time today, so I am going back Wednesday so I can tell you more about him, and the Emuracenter, which is doing a lot of interesting things for the diagnosis and treatment of gastric cancers..

Plans for the upcoming week..

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While I am still finalizing some of my interviews for the week – it’s looking promising, so far..

Plans to go to the OR with Dr. Buitrago (thoracic surgeon) and Dra. Stella Martinez (thoracic surgeon)

To the operating room, and interview with Dr. Maldonado (cardiac surgeon) – and we’ll see if I was just imagining that southern accent..

Interview with Dr. Fabian Emura, gastric cancer specialist, and general surgeon.

Emailed several more orthopedic surgeons and neurosurgeons, so hopefully, I’ll hear back..

In the OR with Dr. Roosevelt Farjardo, General Surgeon

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It’s been two months since my initial visits to see Dr. Fajardo, general surgeon and administrator at Santa Fe de Bogota, so I thought it was time to check back in (and check out the operating room). 

Dr. Roosevelt Fajardo, General Surgeon

Dr. Fajardo was assisted during the case by Dr. Carlos Felipe Perdomo, general surgeon. In addition to operating, Dr. Fajardo is responsible for several new and innovative programs at Santa Fe de Bogota, including a 14 specialty telemedicine service which brings specialty consultations to patients in remote areas of Colombia.

New article at Colombia Reports.com

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Bogota’s Hottest Young Surgeons is my latest article on Colombia Reports – talking about some of the great young surgeons here in the capital;

1. Dr. Juan Pablo Umana (cardiac surgeon)

2/3. Dr. Ivan Santos and Dr. Freddy Sanabria, (plastic surgeons)

4. Dr. Costanza Moreno (orthopedics)

5.  Dr. Juan Carlos Garzon (thoracic surgeon) and

6. Dr. Jose Felix Castro (general surgeon)

and some of the things they are doing (which all of my loyal readers already know all about!)

It was a different style of writing than I am used to – but I enjoyed it, and hope to do another article in the future.

Update: After getting a few requests – I’ve re-posted the article here.  (But, I’d appreciate it if you went to Colombia Reports anyway, so the editors can know how many people are reading the articles – and hope that they will publish more in the future!)

From Colombia Reports.com

Bogota’s Hottest Young Surgeons
Don’t let their youth fool you. These young Bogota surgeons are well versed in the latest technologies and the newest surgical techniques, and are changing the face of, and bringing new sophistication to the capital’s medical community.

Colombia news - docDr. Juan Pablo Umana, 46, Cardiac surgeon

A Bogota native, Dr. Juan Pablo Umana, with his Stanford education, quintessential rugged good looks and a refreshing outlook, brings a California flavor to Fundacion Cardioinfantil, where he has been the Chief of Adult Cardiac Surgery since 2004.  He, along with Dr. Nestor Sandoval have ushered in a new era of Cardiac Surgery in Bogota with a expanding and state-of-the-art cardiac surgery service line.  Notably, in 1997, Dr. Umana along with Dr. Memhet Oz invented the first mitral clip for percutaneous valve repair. During surgery, he is focused, meticulous and unflappable.  Despite being the most senior of the surgeons listed here, he is just hitting his stride.

Colombia news - doc

Dr. Ivan Adolfo Santos, 41, Plastic Surgeon

Dr. Ivan Santos operates at Clinica Shaio, and is one of a trio of celebrity plastic surgeons here in Bogota. Genetically blessed, he looks ten years younger than his 41 years. In spite of his boyish good looks and shy nature, Dr. Santos is a confident and talented surgeon; more importantly, he gets results. Watching Dr. Santos operate is similar to watching a symphony conductor orchestrate classic music composures with 160 musicians. He never misses a beat, and he is simultaneously aware of everything around him. With his precision in the operating room and aggressive post-operative therapies, patients recover faster, with less pain, and leave his office looking and feeling their best.

Colombia news - doc

Dra. Constanza Moreno Serrano, 40, Orthopedic Surgeon

Dra. Constanza Moreno is orthopedic surgeon specializing in hand and microsurgery such as digital reattachment after traumatic injury, reconstructive surgery and correction of congenital deformities. After training with the famed Dr. Harold Kleinert and Dr. Breidenbach III in Louisville, Kentucky, she returned to Bogota in 2005.  She is currently developing a hand transplant program for victims of landmines. Next week, she is presenting her proposal at the International Hand and Composite Tissue Allotransplantation Society in Atlanta, Georgia.

Colombia news - doc

Dr. Juan Carlos Garzon, 39, Thoracic Surgeon

Dr. Juan Carlos Garzon is a man of action; operating at several facilities across Bogota. Trained in Hong Kong, Dr. Garzon excels at the more difficult thoracic cases. As one of just a few board-certified thoracic surgeons in Colombia, he is using video-assisted thoracoscopy to able to treat complex disease with minimal incisions.  He is also teaching this technique to surgeons across Colombia. During cases, he is relaxed, controlled and ready for anything.

Colombia news - doc

Dr. Freddy Sanabria S., 38, Plastic Surgeon

Dr. Freddy Sanabria, a young Richard Gere look-a-like, makes his own pretty women as one-half of the Sanabria plastic surgery practice. Trained at the University of Pennsylvania and Stanford University, he brings skill, dedication and the latest cosmetic innovations to a well-established surgical clinic. While operating, he is confident, focused and detail oriented, and his surgical team anticipates his every need.

Colombia news - doc

Dr. Jose Felix Castro, 37, General Surgeon

Dr. Jose Felix Castro is a staff surgeon at Clinica del Country. This magna cum laude academic scholar is one of a few of the talented young general surgeons in Bogota who have embraced single port laparoscopy, which means abdominal surgery without a scar. While Dr. Castro is the youngest of our line up, he brings a wealth of experience to the operating room.

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