imageWelcome to the December issue of The Surgeons’ Lounge. We have been honored throughout the year by having had the opportunity to feature experts in their respective fields who provided thought-provoking and timely insight, in response to our readers’ questions and comments. In this last issue for 2012, we will not include a guest expert, but instead we will challenge our readers and present three Surgeon’s Challenges!

This month, the “History and Other Facts” column features Emil Theodor Kocher, MD, Swiss physician and Nobel laureate (1841-1917).

The January 2013 issue will kick off with our guest expert, Manoel Galvao Neto, MD, scientific coordinator of Gastro-Obeso Center, in Sao Paulo, Brazil.

On behalf of the Surgeons’ Lounge team, we wish all our readers happy and safe holidays, and look forward to your comments and questions in the new year.



Samuel Szomstein, MD, FACS
Editor, The Surgeons’ Lounge
Dr. Szomstein is associate director, Bariatric Institute, Section of Minimally Invasive Surgery, Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston.

Surgeon’s Challenge No. 1

Collaborators: Boris Hristov, MS, Florida International University; Herbert Wertheim College of Medicine, Miami, and Hira Ahmad, MD (PGY-1), Cleveland Clinic Florida Surgery Residency Program, Weston.

The patient is a previously healthy, 38-year-old white man. His past medical history is negative. He has no allergies and is not taking any medications. He initially presented to his primary care physician with complaints of an extremely painful small lump on his upper right abdomen. He stated that the pain was severe and affecting his quality of life. On physical examination, he had a very small, difficult-to-palpate and exquisitely tender subcutaneous nodule, approximately 1 cm, that was soft and mobile. There were no associated symptoms such as erythema, fever or chills. The rest of his physical exam was benign. Due to the atypical symptoms for such a small, barely palpable nodule, a computed tomography [CT] scan of the abdomen was performed and showed an opacity in the subcutaneous fat (Figure 1).

Figure 1.

Lab results (complete blood cell count [CBC] and comprehensive metabolic rate [CMR]) were within normal ranges. The patient was diagnosed with a possible symptomatic lipoma.

What would you do for this barely palpable but very tender “mass”?

The patient’s surgery to remove the abdominal mass was performed approximately three months after his initial complaint to his primary care physician. Once the initial skin incision was made, the mass was no longer palpable. Good marking of the zone was done preoperatively in the holding area.

What would you do now?

Although the mass was no longer palpable or evident, the subcutaneous fat in the area of the mass was widely excised based on the CT scan findings. The gross appearance of the specimen was not distinguishable from normal adipose tissue and the removed specimen was sent to pathology.

What would you tell the patient?

The pathology report was completed one week later and the mass was identified as a CD34-positive dermatofibrosarcoma protuberans.What would you do now?

Surgeon’s Challenge No. 2

Collaborator: Yaniv Cosacov, MD, University of Debrecen Medical and Health Science Center, Debrecen, Hungary.

A45-year-old women presented for a Roux-en-Y gastric bypass procedure. Her weight was 390 pounds and her body mass index [BMI] was 66.9 kg/m2.

Figure 2.

Her past medical history consisted of multiple medical problems including asthma, hypertension and osteoarthritis, which were treated with bronchodilators and anti-inflammatory drugs (valsartan and hydrocodone/acetaminophen, respectively). Due to poor exercise tolerance and chronic shortness of breath, the patient was essentially bound to her wheelchair (obstructive sleep apnea [OSA] evaluation was negative). She also was diagnosed with dysthymic and anxiety disorders, for which she was treated with several antidepressants and anxiolytics (citalopram, amitriptyline, bupropion and buspirone). She previously had undergone ankle, knee and back surgery, as well as tonsillectomy and sinus surgery.

The patient appeared well and a review of systems and physical examination were all within normal limits. All preoperative lab results and radiological tests were within normal limits. Once access was gained to the peritoneal cavity, the liver appeared enlarged and cirrhotic with multiple, white patchy lesions in all lobes (Figure 2).

What would you do?

Surgeon’s Challenge No. 3

Collaborator: Nicholas L. Cukingnan Lee, MD, Sydney, Australia.

Figure 3.

The patient is a 50-year-old woman who presented to the clinic for a second opinion regarding her epigastric pain, nausea and vomiting that she had had for the past two years. She had undergone a Roux-en-Y gastric bypass with silastic ring (Figure 3) 10 years earlier at an outside facility. Her proton pump inhibitor [PPI] dose was increased and the patient noted improvement of symptoms. One month later, another esophagogastroduodenoscopy [EGD] was performed at our facility, which showed a small ulcer in the jejunum. The patient was admitted the following weekend to treat three episodes of melena. An upper gastroenterologist was then consulted for a double balloon endoscopy, which showed no significant pathology in the jejunal loop and healing of the ulcer. There also was a ring-like dark object seen penetrating the gastric mucosa of the remnant stomach above the pylorus and two ulcers at the points where this object made contact with the gastric mucosa. These findings led to the diagnosis of an eroded gastric ring to remnant.

What would you do if endoscopic removal of this ring was not feasible?

History and Other Facts About …

Emil Kocher

Emil Theodor Kocher, MD (1841-1917)

By Yaniv Cosacov, MD, University of Debrecen Medical and Health Science Center, Debrecen, Hungary.

Emil Theodor Kocher was born and did his life’s work in Bern, Switzerland. Upon his death, an obituary was published in the journal Annals of Surgery, which declared that “the world’s best surgeon has died.”

In Vienna, Kocher studied under Theodor Billroth, considered to be the father of modern abdominal surgery. During that time, a case came along in which a patient, who had a dislocated shoulder for a long time, was brought into Billroth’s theater where Kocher was part of the audience. Every known method was tried to reduce the dislocated shoulder, but none succeeded. Just as efforts were being abandoned, Kocher asked if he could try a technique he had recently developed. Billroth agreed and Kocher succeeded in reducing the shoulder. His technique is still used today.

On Jan. 8, 1874, Kocher performed a total thyroidectomy on an 11-year-old patient, Maria Richsel. In those days, thyroid goiters were operated on only when they were life-threatening: if the thyroid gland closed on the trachea and breathing became impossible. In a preoperative photograph, Maria was taller than her younger sister. Nine years after the operation, another photograph shows her as the shorter of the two siblings. This came to Kocher’s attention, along with the fact that, since the operation, Maria had undergone personality changes, and had become cretinoid in appearance. This prompted Kocher to investigate other of his thyroidectomy patients and he invited them for a checkup at his clinic. This is one of the earliest, if not the first, example of a follow-up study. What he found was a high incidence of myxoedema (named cachexia strumiprivia), especially in children. During the late 1870s, textbooks deemed the thyroid gland a complete mystery in terms of its function and necessity. But with Kocher’s findings, for the first time, a great clue had been found and the mystery of the thyroid gland was unlocked.

Above are the photographs that Kocher published at the time of his discovery of the effects of thyroidectomy. Left: Maria Richsel is taller than her younger sister. Right: nine years after Kocher removed Maria’s thyroid gland, her sister grew taller but Maria remained about the same height.

Kocher performed a second study in which he operated on goiters, but this time, instead of doing a total thyroidectomy, he left a small piece of tissue intact. This tissue was enough to compensate, not only for normal physiology, but also in times of increased demand, such as pregnancy and childhood. This small, keen observation has changed the lives of millions of people for more than 100 years. By 1917, at the time of Kocher’s death, more than 7,000 patients had undergone operations at his clinic, three-fourths of whom he operated on personally.

Kocher was one of the first surgeons to espouse asepsis, and he adopted Joseph Lister’s principles of complete asepsis in surgery. He collaborated with Tavel, whose bacteriologic studies on infective processes he sought to advance. From this work came the second edition of Vorlesungen über chirurgische Infektionskrankheiten (lectures on surgical infectious diseases) (Kocher and Tavel, Basel, Switzerland 1892, and Jena, 1900). Kocher published his statistics religiously: In 1884, the mortality rate was 14%; by 1889, it was 2.4%; and by 1898, it was 0.18%. In his acceptance speech for the Nobel Prize in Physiology or Medicine in 1909, he claimed to have performed more than 300 consecutive thyroid operations without a single death. These statistics made a worldwide impact, and many of the renowned surgeons of that period came to Kocher’s clinic to learn and disseminate this knowledge to their apprentices and colleagues.

Studies of perioperative anxiety states show that lower anxiety yields better wound healing results (especially of the skin), in both pre- and postoperative periods. Kocher believed this to be true, and claimed that the physician should calm the patient both before and after surgery. He did so in such a way that the patient eventually was looking forward to the operation—a status that all of us would like to achieve with our patients!

Perhaps Kocher is less relevant today in the area of treatment methods and surgical techniques, and his work is being regarded and referred to less frequently. However, with his pioneering techniques, he should be regarded more as a source of inspiration rather than a source of information.

Kocher received the Nobel Prize in Physiology or Medicine on Dec.10, 1909, for his work on the physiology, pathology and surgery of the thyroid gland.