Trainees Challenged by the Whipple

The Whipple procedure, or pancreati-coduodenectomy, is the most com-

monly performed surgery for pancreatic cancer, a disease with a notoriously poor prognosis. It also is one of the most com-plex and demanding operations in sur-gery. For surgeons-in-training, mastering the technique may require making the most of every learning opportunity, since cases may be limited. Most residents can count on one hand the number of times

they have performed the Whipple proce-dure by graduation.1

Whipple surgery involves removal of not only the head of the pancreas and most of the duodenum, but also a por-tion of the bile duct, the gallbladder, and associated lymph nodes. In some cases, the surgeon must remove the entire duodenum and part of the stomach, and reconstruct the digestive tract. The

Beginning January 2012, surgical prac-tices around the country will begin

using a new classification system—the ICD-10—to characterize their patients’ medical conditions. Coding is often not high on a surgeon’s priority list. However, the transition from the ICD-9 to version 10 represents a transformation in documen-tation will affect medicine in profound ways, from research to reporting perfor-

mance measures and reimbursement.

“Either through lack of knowledge or lack of interest, I don’t think we as surgeons do a very good job at all [with coding],” said Mark Savarise, MD, a

surgeon at Pend Oreille Surgery Center in Pon-deray, Idaho, who sits on the Amer-

ican College of Surgeons General Sur-

gery Coding and Reimburse-ment Committee. “Coding in general is not taught and there is just no time in res-idency training, so we don’t pay a great deal of attention to the ICD codes.”

If surgeons have historically paid less than rapt attention to coding and docu-mentation, why then should they learn the ICD-10 system now? For 2 reasons, experts say: reimbursement and reputation.

ICD-10 Codes Overwhelming

see ICD-10, page 2

see WhIpple, page 7

INSIDE:

In PracticeSurgeons in training learn the art of teaching.

In Practice Bedside manner is increasingly important in surgical training.

In the FutureExperts discuss the benefits of membership in surgical societies.

The publication for surgical residents and fellows

Vol. 2, Issue 2

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The ICD system, or “International Classification of Dis-ease, Injuries and Causes of Death,” is the basic frame-work used globally by physicians to describe medical conditions and diseases. Formally introduced in the late 1800s, the ICD is routinely revised to reflect advances in medicine and physicians’ understanding of disease.1 The 10th revision, or ICD-10, was formally completed in 1992 and adopted by several countries more than a decade ago. In the United States, medical practices may begin using the ICD-10 codes in January 2012, pro-vided they have also begun using the new Version 5010 standards for electronic health transactions. After a 22-month grace period, all practices must begin using the ICD-10 sys-tem by Oct. 1, 2013.2

“It is dramatically different, an 8- to 10-fold increase in the number of codes,” said Lucian Newman, III, MD, a general surgeon in Gads-den, Alabama, who is also the chief medical officer for ComplyMD, coding and documen-tation software designed to improve sur-geons’ billing. “The basics behind why they are changing is that there is no more room for new disease processes or to further reg-ister the differences that we come across [in practice] as a product of further research.”

Whereas the ICD-9 uses a 5-digit numeric code, the ICD-10 uses a 7-digit alpha-numeric code. The addition of alpha charac-ters and 2 additional values expands the total number of potential codes from 17,000 with ICD-9 to 140,000 with ICD-10.3

Surgeons, like many other physicians, are coming under increased scrutiny through quality reporting and pay-for-performance programs. If surgeons do not accu-rately describe a patient’s comorbidities before surgery, they run the risk of being penalized for substandard care of a “typical” patient who has a complication.

“If doctors do not learn to describe things better they’re not going to get credit for taking care of sick patients,” said Dr. Newman. “My coder may come up with the bill, but it is the doctors’ words that actually create the bill.”

It is important, however, to understand what is chang-ing in the health care documentation system. Current Procedural Terminology (CPT) codes, which determine a surgeon’s payment for an operation, are not affected by the ICD changeover but must follow the appropriate diagnostic ICD code. “The most common problem [in billing] is that you have to link your CPT to an appropri-ate diagnosis in order to get paid for it,” said Dr. Savarise.

For example, if a surgeon resects a cancer in a patient who needs intensive care unit (ICU) care for respiratory failure, in order to get paid for the ICU care, the surgeon has to show that it was precipitated by the respiratory failure, not as part of the postoperative cancer care.

According to the Centers for Medicare & Medicaid Ser-vices, the expanded code set will provide a number of advantages to physicians, insurance payers, and the fed-eral government, including better quality measurements, a reduction in coding errors, better analysis of disease pat-terns, better tracking and response to public health out-breaks, more efficient claims submissions, and better

identification of fraud and abuse within the Medicare and Medicaid systems.4

For surgeons, the ICD-10 includes 2 new aspects that provide significantly greater specificity: combinations that allow surgeons to document secondary conditions and codes for complications.

Approximately 50 different codes will cover hernias, depending on the type of her-nia diagnosed (eg, inguinal, femoral, umbili-cal, etc.) and the subcategory. Within inguinal hernias, for example, there are subcategories for direct, double, indirect, oblique bubono-cele, and scrotal hernias.

In terms of complications, all hernia cat-egories have specific codes for obstruc-tion, gangrene, and for no obstruction or gangrene. An obstructed hernia may then be further classified as incarcerated, irre-ducible, or strangulated. If an intervention

is warranted, a surgeon would use the fourth through sixth characters to code for the location of the hernia, the approach (eg, open, laparoscopic, or transthoracic), and the type of mesh used.

Many resources are available for surgeons who wish to learn more about effective coding. For an introduction, please visit the American Academy of Professional Cod-ers at www.aapc.com. For advanced training, the Amer-ican College of Surgeons has a number of resources under the “Practice Management” section of www.facs.org, including a coding manual designed for residents and young surgeons and a listing of coding and practice man-agement workshops.

References1. History of the development of the ICD. World Health Organization. http://www.who.

int/classifications/icd/en/HistoryOfICD.pdf. Accessed October 13, 2011.

2. The ICD-10 page. Center for Medicare & Medicaid Services. http://www.cms.gov/icd10/. Accessed October 13, 2011.

3. Rhonda Buckholtz. The ICD-10 Will Change Everything. Centers for Medicare & Medicaid Services Web site. http://www.cms.gov/ICD10/Downloads/AAPCICD-10WillChangeEverything.pdf. Accessed October 13, 2011.

4. Denise Buenning. The Transition to Version 5010 and ICD-10: An Overview. Cen-ters for Medicare & Medicaid Services Web site. http://www.cms.gov/ICD10/Downloads/CMSICD-10Overview.pdf. Accessed October 13, 2011.

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In PractIce

ICD-10continued from page 1

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Surgeons Learn the Art of Teaching

One of the roles physicians play is that of teacher. Teaching happens at every level—interns educate

students, residents teach interns, fellows teach residents, and attending physicians teach them all. Decades ago, medical training institutions began to recognize that trainees should be prepared to teach.1 But when Mylene Dandavino, MD, began researching teaching skills for students during medical school, she found very little lit-erature. But she did discover some compelling arguments for why these skills are important—medical students who understand teaching and learning principles and tech-niques ultimately become better at both.2

Residents may spend up to one-fourth of their work time instructing others and oftentimes they are asked to fill in the teaching gaps at their institutions.3,4 Unfortunately, the lack of teacher training at the student level means resi-dents may get their earliest training from individuals who are not necessarily qualified to teach education skills.

Just as medicine and surgery are evidence-based scien-tific fields, so too is education. “[Education] is a well-stud-ied field and it behooves educators to become familiar with some of the research on education and teaching,” said David Uttal, PhD, professor of psychology and edu-cation at Northwestern University in Evanston, Illinois.

One central educational theory is the notion of trans-fer of training. “We evolved to remember information in context, not to memorize lists of facts,” Dr. Uttal said. The trick is figuring out how to encode information to increase the chance that the learner will be able to recall that infor-mation in the appropriate setting. This requires creativity when choosing examples because surgery requires a great deal of baseline knowledge coupled with the ability to quickly apply it in a variety of problem-solving scenarios.

Teachers should ensure that the transfer of knowledge is flexible and adaptive.5 If the student can apply a new skill to multiple or unrelated contexts it increases overall com-prehension. This is achieved when the student is taught how to extract underlying themes and principles from the knowledge and decides when and how to apply it.5

Effective communication is another vital skill for teach-ers.2 “The person teaching may think he or she is com-municating a general principal, but to the learner, the characteristics of that example become the most salient,” Dr. Uttal said. “You might be illustrating a general point about physiology, but the specific organ system you’re talk-ing about will be what’s remembered. Give multiple, related examples that help people generalize their knowledge.”

Another important facet of learning is visuospatial rea-soning. Textbooks have become diagrammatic so readers can draw connections between pictures and text but this may take longer with new learners. “Be mindful that the

connection between what you’re saying and what you’re showing may not be drawn immediately,” said Dr. Uttal. “Medical diagrams are complex. As the teacher, we forget that this is a whole constructive process for the novice.”

There’s also the principle that less is more. In fact, too much information can muddy the message. Scott Enebo, a

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Editorial Board

Frederick Greene, MD

Chairman, Department of SurgeryCarolinas Medical CenterClinical Professor of SurgeryUniversity of North Carolina at Chapel Hill School of MedicineChapel Hill, NC

William B. Inabnet, MD

Chief, Division of Metabolic, Endocrine and Minimally Invasive SurgeryDirector of Surgical Sciences, Metabolism InstituteMount Sinai Medical CenterNew York, NY

Adrian Park, MD

Campbell and Jeanette Plugge Professor Vice Chair, Department of SurgeryHead, Division of General SurgeryUniversity of Maryland Medical CenterBaltimore, MD

J. Scott Roth, MD

Associate Professor of SurgeryCommonwealth Professor of Minimally Invasive SurgeryChief of Gastrointestinal Surgery and Director of Minimally Invasive SurgeryUniversity of Kentucky, College of MedicineLexington, KY

Supported by

545 West 45th Street, New York, NY 10036. Printed in the USA. All rights reserved, including the right of reproduction, in whole or in part, in any form. December 2011.

Copyright © 2011

CUSTOM MEDIA

Publisher ofFutura BT 66pt & Futura Extra Bold Condensed Oblique 66pt

In PractIce

see TeaChIng, page 4

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Bedside Manner: Treat With Patience

Despite the increasing pressure on surgeons to treat higher volumes of patients, the few studies examin-

ing surgeon–patient interactions indicate that surgeons are doing a good job when it comes to bedside manner.

A survey of patients with pancreatic cancer found that 96% used positive words such as “patient,” “warm,” “under-standing,” or “supportive” to describe the demeanor of their surgeon during their initial meeting. Moreover, after hospitalization for their pancreatic resections, patients rated their surgeon’s emotional support as 8 out of 10.1

That being said, out of all the medical specialties, sur-geons often are anecdotally considered to have poor bed-side manner. “Surgeons are very rushed because they have demands not only from their patients, but also from the operating rooms,” said Kay Ball, PhD, associate professor of nursing at Otterbein University in Westerville, Ohio, who managed operating room suites for more than a decade as a perioperative nurse.

The available data on surgeon–patient interactions show that basic communication skills can go a long way toward improving patient perceptions (Table).2,3 For example, using a patient’s first name or verifying that they understand the treatment reflect positively on surgeons.2

A recent study on communication training for surgical

residents showed that after a series of brief seminars, case-specific interactions with patients improved signifi-cantly.4 Based on this finding, the authors recommended that residency programs adopt a simple communication initiative into their curriculum.4

Robert S. Bray Jr, MD, a neurological spinal surgeon who founded the Diagnostic and Interventional Sports and Spine Center in Marina del Rey, California, believes surgical training does not emphasize bedside manner enough. “The interactions with patients are limited, so it’s tough for them to develop bedside manner,” said Dr. Bray, who has been training medical students, residents, and fellows for 27 years. A way to develop this skill is by observing attending physicians who embody and prac-tice effective communication.

However, there are basic steps that a surgeon can take to improve his or her bedside manner, which Dr. Bray believes can be taught. The first step is to be punctual. “I tell my [22] doctors it’s more important for them to be on time than the patient,” he said. When he is with patients, Dr. Bray also emphasizes sitting with a patient and exam-ining them, even if a resident or fellow already has done so. “I show every patient their films and I discuss them in terms they understand,” he said. The most important step,

training consultant with the Bob Pike Group, an organiza-tion that offers training seminars on teaching for a variety of industries, echoed this sentiment. “We help hone the con-tent down; more content can have a tendency to confuse what competencies we are trying to develop in people.”

To confirm that a concept is adequately grasped by the students, teachers can apply deliberate practice with feedback.2 Teachers may have students take on the teach-ing role and explain the new concept in their own words. The teacher can then offer feedback; additionally, this type of model encourages greater self-awareness on how the student may learn.2

Along these lines, students should be nurtured toward becom-ing self-guided learners. A motivated student can

acquire information on his or her own. “But they need to be able to interpret it. So giving students information searching skills and understanding,

reasoning, and critical thinking are perhaps more important

than the sheer commu-nication of knowledge,” Dr. Uttal said.

The current debate over implementing formal teacher training in medical school is that adding one item to the curricula requires dropping another. But there are ways to implement “learn-to-teach” activities into the curricu-lum, such as integrating teaching skills with communication lessons.2 Small-group activities, team-based learning, and individualized instruction using technology can be used for instruction and assessment.1 A formal curriculum should provide students with knowledge about the principles of education, improve their teaching skills and strategies, and change their attitudes about teaching.2

Ultimately, teaching does not merely instruct those receiv-ing the information. “They say that teaching is learning twice; practicing teaching makes students better learners,” said Dr. Dandavino, now a hospitalist at the Montreal Children’s Hos-pital and assistant professor of pediatrics at McGill University.

References1. Searle NS, Hatem CJ, Perkowski L, Wilkerson L. Why invest in an educational

fellowship program? Acad Med. 2006;81(11):936-940.

2. Dandavino M, Snell L, Wiseman J. Why medical students should learn how to teach. Med Teach. 2007;29(6):558-565.

3. Seeley AJE. The teaching contributions of residents. CMAJ. 1999;161(10):1239.

4. Kowalczyk L. Harvard sweetens reward for doctors who teach. Boston Globe. http://www.boston.com/news/local/articles/2007/03/09/harvard_sweetens_reward_for_doctors_who_teach/. Accessed September 30, 2011.

5. Bransford JD, Brown AL, Cocking RR, eds. How People Learn: Brain, Mind, Experience, and School. Washington, D.C.: National Academy Press; 2004.

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TeaChIngcontinued from page 3

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particularly for surgeons-in-training who will be entering community practice, is to resist the pressure to increase patient volume. “The pressure to make another dollar—you have to resist that,” said Dr. Bray. He might see 3 or 4 new patients in an afternoon, but he spends at least 45 minutes with each of them. “I end every session by asking, ‘Do you have any further questions?’,” he said. Dr. Bray’s approach is validated in surveys of surgical patients. Failing to ask whether the patient has questions and failing to sit down with them were the 2 most common reasons that surgeons were not recommended to family members or friends.3

The Centers for Medicare & Medicaid Services now includes patient satisfaction scores to calculate hospital reimbursements. Institutions must administer the survey and report this data. Failure to do so will result in a 2% reduction in hospital reimbursement.5

Medical practices are beginning to see the value in cre-ating a culture of positive bedside manner. Some prac-tices survey their patients about the quality of care they received and use patient satisfaction scores to calcu-late 20% of a physician’s salary. Other institutions with-hold some or all of a physician’s annual bonus if he or she receives poor ratings.6 A nurturing demeanor has yet another benefit—fewer malpractice suits. A study of 353 physicians and their patient satisfaction scores found that those in the middle tertile had 26% more malpractice suits than those in the top-scoring tertile. Physicians in the bot-tom tertile of satisfaction scores had 110% more malprac-tice suits than those in the top tertile.7

Incidentally, despite Dr. Bray’s lower patient volume, his attention to bedside manner may lead to higher reve-nues. “I probably see fewer patients than the next guy, but I actually do more surgeries,” he said.

References1. D’Angelica M, Hirsch K, Ross H, Passik S, Brennan MF. Surgeon-patient

communication in the treatment of pancreatic cancer. Arch Surg. 1998; 133(9):962-966.

2. Wallace LS, Cassada DC, Ergen WF, Goldman MH. Setting the stage: Surgery patients’ expectations for greetings during routine office visits. J Surg Res. 2009; 157(1):91-95.

3. McLafferty RB, Williams RG, Lambert AD, Dunnington GL. Surgeon communication behaviors that lead patients to not recommend the surgeon to family members or friends: Analysis and impact. Surgery. 2006;140(4):616-622; discussion 622-624.

4. Chandawarkar RY, Ruscher KA, Krajewski A, et al. Pretraining and posttraining assessment of residents’ performance in the fourth accreditation council for graduate medical education competency. Arch Surg. 2011;146(8):916-921.

5. Medicare Program; Hospital Inpatient Value-Based Purchasing program. Fed Regist. 2011;76(88):26490-26547.

6. Kolata G. “When the doctor is in, but you wish he weren’t.” The New York Times. http://www.nytimes.com/2005/11/30/health/30patient.html?pagewanted=1&_r=1. Accessed October 8, 2011.

7. Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005;118(10):1126-1133.

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Paradigm Shift in Medical Education

Over the past 2 decades, medical educators have started to challenge some of the assumptions found in the Flexner Re-

port, which provided the framework for medical school curricula in America.1 As Abraham Flexner himself noted in 1925,2 when students intensively focus on the basic sciences, they may lose sight of the humanistic side of medicine.

Patient contact is becoming an increasingly common compo-nent of the first weeks of medical school. In addition to anatomy and physiology, many programs’ first-year curricula include a class focused on patient care. Patients often will come and speak about their medical condition and interact with students, and cases are used to illustrate basic scientific concepts. It also is common for students to shadow clinical professors or adjunct faculty at their community practices.3

“From the educators’ side of things, we hope that students get an earlier sense of responsibility, a feel for the gravity of what they are going to be doing as a physician,” said Rebecca Evange-lista, MD, associate professor of surgery and director of the gen-eral surgery clerkship at Georgetown University Medical Center, in Washington, DC. By introducing patient contact earlier in stu-dents’ training, educators hope that a disease process will always be seen within the human context.

Mary Ann Hopkins, MD, has observed a shift in the way medical students communicate with patients as a result of this changing paradigm. “You used to see [medical students] trying to explain to a patient what a sentinel lymph node biopsy for breast can-cer was in a medical way that is completely incomprehensible to a patient,” said Dr. Hopkins, associate professor of surgery and director of clinical education at New York University School of Medicine in New York City.

As a result of earlier interactions with patients, medical stu-dents don’t become accustomed to medical jargon. Instead, they have been developing clear, simple communication skills through-out their education; while improving their bedside manner.

References

1. Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the Advancement of Teaching, bulletin number 4. http://www.carnegie-foundation.org/publications/medical-education-united-states-and-canada-bulletin-number-four-flexner-report-0. Accessed September 21, 2011.

2. Flexner A. Medical Education: A Comparative Study. New York, NY: The MacMillan Company; 1925.

3. Smithson S, Hart J, Wass V. Students’ hopes and fears about early patient contact: lessons to be learned about preparing and supporting students during the first year. Med Teach. 2010;32(1):e24-e30.

In PractIceTable. Tips for Effective Bedside Manner

Take the time to properly introduce yourself

Devote time to patients for discussing their situation

Show interest in the patient’s condition/outcome

Speak in terms the patient can fully understand

Ask the patient if he or she has any questions

Appear relaxed

Maintain eye contact

Respect the patient by arriving on time or apologize if late

Express hope for the patient’s outcome/well-being

Do not take notes and listen at the same time

Examine the patient yourself

Adapted from references 2 and 3.

www.intrainingsurgery.com

Surgical Societies: What’s in It for Me?

Kyla Terhune, MD, believes in the benefits of society membership for surgical residents, even though she

admits the process is overwhelming. “There are so many choices,” said Dr. Terhune, who recently completed her general surgery residency at Vanderbilt University School of Medicine in Nashville, Tennessee. How does a resident or fellow decide which society to join, if any?

The American College of Surgeons (ACS) Web site offers a list of more than 30 professional surgical societies; most allow residents and fellows to join.1 Each society charges annual fees and expects all members to make certain com-mitments so joining all of them is impossible (Table).2-4

“Years ago, we all used to join the societies as residents,” said J. David Richardson, MD, professor and vice chairman of surgery, University of Louisville School of Medicine in Kentucky. “But that’s not the case anymore. There are a lot of reasons for that, including time and cost.” Before join-ing any of the societies, Dr. Terhune advises that residents and fellows “listen to their mentors.” Most residency pro-grams across the country advocate society membership. Some even help offset the costs associated with member-ship dues and travel to meetings, added Dr. Richardson.

The ACS, founded in 1913, is the largest and arguably the most well-known professional society in surgery.5 Accord-ing to Paul E. Collicott, MD, FACS, director, Division of Member Services for the ACS, a new class of roughly 1,400 residents is accepted into the fellowship program each year. Dr. Terhune describes benefits as “immeasurable.”

However, not everyone agrees. John Migaly, MD, FACS, FASCRS, associate program director of General Surgery Residency at Duke University Medical Center in Durham,

North Carolina, said that although the ACS is a “good first society” to join, residents who wish to practice in aca-demia or in major hospitals where research is the focus” should look into what Dr. Migaly calls “the specialist soci-eties.” The Society of American Gastrointestinal and Endo-scopic Surgeons is one of the many specialty societies. For those intent on pursing careers in research or academia, the Association for Academic Surgery is one to consider.

One of the advantages of society membership is the abil-ity to present or publish original research. “We want our residents to take time out for basic and clinical research [and] we see societies as an avenue to publish their work” said Dr. Migaly. “ We want them to think of themselves as future leaders.” Membership also offers invaluable net-working opportunities for surgeons-in-training. Dr. Rich-ardson believes that person-to-person contact still is the best way to learn certain aspects of being a professional surgeon. “I think people who embrace professional societ-ies don’t burn out as much as those who do not,” said Dr. Richardson. So is it worth it? “You see the dues, and you wonder but the benefits are so great,” said Dr. Terhune, now an attending surgeon at Vanderbilt University Medical Center. “It’s definitely worth it.”

References1. Other surgical societies of interest. http://www.facs.org/fellows_info/other_sites/

othersurgsoc.html. Accessed September 23, 2011.

2. Applications. http://www.facs.org/memberservices/documents.html#application. Accessed October 3, 2011.

3. Requirements and applications for candidate membership in SAGES. http://www.sages.org/membership/candidate. Accessed September 22, 2011.

4. Membership in the association. http://www.aasurg.org/membership. Accessed September 8, 2011.

5. About the ACS. http://www.facs.org/about/corppro.html. Accessed September 23, 2011.

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Table. The Price of Membership for Residents and Fellows

Society Application Fee Annual Dues

ACS (www.facs.org/about/corppro.html) $20 $20

FACS (www.facs.org/members/benefits/index.html) $75 $200

SAGES (www.sages.org/membership/candidate) $60, due with submission of candidate membership application

ASMBS (www.asbs.org/Newsite07/healthcareprof/membershipinfo/asbs_membership_prof.htm)

$50 $35

FASCRS (www.fascrs.org/physicians/become_a_member) Fellows: $200 Fellows: $300 Residents: $25, due with submission of application

AAS (www.aasurg.org/membership) $15 for candidate members $230 for active members

AHS (https://www.americanherniasociety.org/membership-application)

$25 $25

AAS, Association for Academic Surgery; ACS, American College of Surgeons; AHS, American Hernia Society; ASCRS, American Society of Colon and Rectal Surgeons; ASMBS, American Society for Metabolic and Bariatric Surgery; FACS, Fellows of the American College of Surgeons; FASCRS, Fellows of the American Society of Colon and Rectal Surgeons; SAGES, Society of American Gastrointestinal and Endoscopic Surgeons

Based on references 2-4.

www.intrainingsurgery.com

surgery, which also is indicated for some benign pancreatic conditions, can take 4 to 8 hours to complete. The num-ber of required steps and potential complications make the Whipple procedure both an exciting challenge and a dangerous proposition.

“In that area of the duodenum and the pancreatic head that you’re removing—an area of about a 10-cm circle—you’ve got probably more vital structures than any other place in the abdominal cavity,” said Phillip D. Price, MD, FACS, American Cancer Society liaison physician for the Mount Carmel Health System in Columbus, Ohio.

The Whipple operation has 3 phases, according to Chris-topher L. Wolfgang, MD, PhD, FACS, associate professor of surgery, pathology, and oncology, and director of pancre-atic surgery at Johns Hopkins University School of Medi-cine in Baltimore. The first phase is a thorough exploration of the abdomen to identify tumor implants or liver metas-tases that were not seen during the preoperative staging work-up. “If manual palpation is not decisive, intraopera-tive ultrasonography may be used to further assess the liver parenchyma,” Dr. Wolfgang said. “This phase is ame-nable to laparoscopic exploration in most patients.” Due to the limitations of preoperative imaging, small perito-neal implants are the most common unexpected finding during exploration, he added. The relationship of tumor to vessel is best seen on a pancreas protocol computed tomography (CT) scan before surgery. “A pancreas proto-col CT scan is absolutely essential,” said C. Max Schmidt, MD, PhD, MBA, associate professor of surgery, biochemis-try, and molecular biology at the Indiana University School of Medicine in Indianapolis. “There are variants of hepatic arterial anatomy in patients that are optimally known prior to performing a Whipple procedure.” It also is important to assess the anatomy that results from previous operations, such as a palliative bypass, in order to formulate a plan for enteric reconstruction, Dr. Wolfgang added.

The second phase of the operation includes exposure of the periampullary region followed by resection of the pancreatic head, duodenum, antrum, distal bile duct, and tumor. It involves a complex series of maneuvers that often takes years of training to master. During this criti-cal phase, surgeons can run into a number of potentially devastating problems, including vessel injury, major hem-orrhage, and the compromise of sound oncologic prin-cipals, Dr. Wolfgang noted. Surgeons should be wary of anomalous arterial vasculature after dividing the retroper-itoneal attachments of the duodenum, he said, because ligation of a major hepatic artery can result in fatal hepatic necrosis. The most common anomaly is a replaced right hepatic artery; others include an accessory right hepatic and replaced common hepatic arteries.

During the numerous and complicated resections of this phase, achieving a clear margin by dividing the uncinate process from the superior mesenteric artery (SMA) can be as difficult a step as it is an important one, according to Dr. Wolfgang. “There is only one chance to obtain a retroperi-toneal/uncinate margin that is free of tumor,” he said. “The dissection of the uncinate from the SMA must begin in the correct plane and be carried through this plane until the specimen is removed. The right lateral border of the SMA should be exposed to the level of the adventitia. If this is not done and soft tissue is left behind, there is really no way to go back and dissect it off the artery.”

Finally, the third phase consists of reconstruction of the enteric tract through creation of 3 anastomoses: the pan-creaticojejunostomy or pancreaticogastrostomy, hepat-icojejunostomy, and gastrojejunostomy for a standard pancreaticoduodenectomy or duodenojejunostomy for the pylorus-preserving version. Upon reconstruction, the pan-creaticojejunostomy is the most likely of the 3 to leak, said Dr. Wolfgang, who places drains near that anastomosis to identify and control leakage. He typically places an addi-tional drain in the area of the hepaticojejunostomy.

Surgeons should pay attention to every stitch for each of the anastomoses of a Whipple operation. “That anastomo-sis is only as good as your worst stitch,” Dr. Price said. “You can put in 100 stitches and 99 of them could be great, but if 1 of them is bad, that may causes the problem.”

Although many factors “make or break” such a com-plex operation, some key elements to success include (Table) proper patient selection, obtaining a tumor-free retroperitoneal/uncinate margin, and effective res-olution of complications, Dr. Wolfgang said. Before the operation, surgeons should select patients for their per-formance status, ability to tolerate a large operation, and tumor factors (ie, spatial relationship to vessels, extent of

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In technology

WhIpplecontinued from page 1

Table. Whipple Procedure Tips for Success

Learn well the anatomy of the abdominal cavity

Observe and assist in as many Whipple procedures as possible

Choose patients who will tolerate and benefit from the procedure

Map out the abdominal cavity carefully with imaging technology and manual exploration

Look for anomalous arterial vasculature to avoid ligation of a major hepatic artery

Obtain a tumor-free retroperitoneal/uncinate margin

Minimize and control leakage, bleeding, and sepsis

Based on advice from Drs. Chalikonda, Price, Schmidt, and Wolfgang.

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systemic spread, and tumor biology). During the opera-tion, proper dissection of the uncinate from the SMA (as described above) is critical. Although it does not always result in an R0 resection, it offers the best chance of a margin-negative resection, Dr. Wolfgang said. After the operation, both “overtreatment” and “undertreatment” of complications can result in an undesirable outcome, he said. The most common complications are delayed gastric emptying, postoperative pancreatic fistula, and wound infection.

Dr. Schmidt recommended that residents do what they can to prevent sepsis during surgery (eg, timely antibi-otics, chlorhexidine skin preparation, skin and wound protection, frequent glove changing, saline irrigation, keeping the patient warm). Additionally, residents should be meticulous in their efforts to minimize blood loss and trauma. “Take the time to do it right,” he said. “This means the operation may take longer. But I think that attention to detail is in the patient’s best interest. Patients who have less blood loss and don’t get transfused with blood during or after the operation have better outcomes.”

Young surgeons interested in learning the Whipple procedure can begin with textbooks and atlases. Current Surgical Therapy, written by esteemed Whipple expert John L. Cameron, MD, is an essential. “Cameron’s text-book of surgery is a great resource for not just learn-ing the steps of the operation, but also the indications and preoperative and postoperative management of these patients,” said Sricharan Chalikonda, MD, staff sur-geon in the Department of General Surgery and direc-tor of robotic surgery at the Digestive Disease Institute of the Cleveland Clinic in Ohio. Like most things in life, practice makes perfect, and the Whipple procedure is no exception. As a resident, the only option may be to watch from the sidelines, but that can be an invaluable learning experience. “Complex surgeries, like a Whipple, you start to learn by standing there, holding the retrac-tor, and watching. Or standing there, holding the laparo-scope, and watching,” Dr. Price said.

Speaking from personal experience, Dr. Schmidt encourages surgeons-in-training to get into the oper-ating rooms (ORs) of attendings they wish to emulate, observe them in action, and note the steps they take dur-ing surgery. “I still have a book of the steps my teach-ers used to do the Whipple operation and other complex major operations,” Dr. Schmidt said.

Getting into the OR also can be a good way to become familiar with how different surgeons employ new tech-nology to the Whipple, especially energy-delivery

devices (Figure). Electrocautery and gastrointestinal anastomosis staplers are commonly used for both lap-aroscopic and open procedures. Drs. Price, Schmidt, and Chalikonda regularly use Harmonic® devices (Ethi-con Endo-Surgery). “It allows you to dissect all these lit-tle vessels that you might have to take down and ligate, and that you could not control with the electrocautery. I think it facilitates the dissection because it speeds it up [compared to clamp, cut, and tie] and it also allows you to keep the field relatively bloodless,” said Dr. Price, who counts advanced laparoscopic surgery as an area of specialty, but only performs open Whipple procedures. In addition to staplers and electrocautery, Dr. Wolfgang uses an argon beam coagulator to control minor venous bleeding from retroperitoneal surfaces. He noted using energy devices for the new laparoscopic approach to pancreaticoduodenectomy.Dr. Chalikonda and his col-leagues began using energy devices in open Whipple procedures after finding them useful in laparoscopic pro-cedures. “I don’t think that we would be able to perform our laparoscopic cases safely without advanced energy devices,” he said.

Dr. Schmidt uses energy devices as well. “The Har-monic® is what I predominantly use. It’s slender, there’s a nice curve on it,” he added. The latest generation of Harmonic® devices can seal blood vessels up to 5mm in diameter. “There’s a lot of vascularity to the dissection and having that long, slender instrument to do the dissec-tion as opposed to clamp, clamp, cut, cut and tie, which is the old way that I did everything, allows me to be able to do more in a smaller space,” said Dr. Schmidt.

A great deal of clinical experience is, in the end, the only way to master the Whipple procedure. “These are chal-lenging operations [even] for those of us who do them routinely,” Dr. Chalikonda said. “And there’s no replace-ment for experience. The more you do, the more you see, the better you’re going to get at it.”

References1. Helling TS, Khandelwal A. The challenges of resident training in complex hepatic,

pancreatic, and biliary procedures. J Gastrointest Surg. 2008;12(1):153-158.

2. Cameron JL, Cameron AM. Current Surgical Therapy. 10th ed. Philadelphia, PA: Elsevier Inc., 2011.

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In technology

This article is sponsored by Ethicon Endo-Surgery. As with any surgical procedure, the Whipple procedure may present risks. Individual patient results may vary and are not indicative of all outcomes. Patients should consult their physicians to find out if this procedure is appropriate for their condition. This article contains discussion/comments that are a compilation from surgeon interviews. The opinions and conclusions expressed may not necessarily reflect the views of Ethicon Endo-Surgery. The article discusses the use of surgical devices; it is not intended to be used as a surgical training guide. Other surgeons may employ different techniques. Individual surgeon preference and experience should always dictate variation in procedure steps. Before using any medical device, including those demonstrated or referenced in this article, review all relevant package inserts, with particular attention to the indications, contraindications, warnings and precautions, and steps for use of the device.

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Figure. HARMONIC Focus® Long Curved Shears.