We are board certified general surgeons and Fellows of the American College of Surgeons. People often wonder exactly what those terms mean. A general surgeon is a physician who has completed an internship and residency at a Residency Review Committee approved program. Most of these are University based and offer rotations at busy private and county or VA hospitals. The residency is a minimum of five years.
The last year is spent as Chief Resident where one is in charge of a team of junior residents and medical students and performs between 250 and 350 major cases. There are strict criteria for the number and variety of cases that one is exposed to. The residency is considered to be one of the most demanding, both mentally and physically, of all the medical specialties.
A general surgeon is well trained in the diagnosis and management of a wide variety of congenital, infectious, malignant and benign diseases. In addition, he or she has extensive knowledge of postoperative and critical care of patients.
A Board Certified General Surgeon is one who has completed the standard surgical residency with experience in a broad spectrum of surgical diseases and a minimum number of cases as set by the board.
He or she has passed a day-long written examination verifying an extensive knowledge base, and passed an oral examination. During the oral exam, candidates are interviewed by three teams of prominent surgeons who evaluate the candidates' ability to manage ordinary and complex surgical problems.
For more information about board certification, see the American Board of Medical Specialties and the American Board of Surgery.
The initials F.A.C.S. indicate that the physician is a Fellow of the American College of Surgeons. To achieve this status, the surgeon's education and training, professional qualifications, surgical competence, and ethical conduct have passed a rigorous evaluation and have been found to be consistent with the high standards established and demanded by the college.
To apply, the surgeon must be in the same practice for more than two years and accumulated a certain number of cases. The application process takes another year. For more information, see the American College of Surgeons.
A surgeon who has attained certification by the American Board of Surgery has specialized knowledge and skill relating to the diagnosis, preoperative, operative, and postoperative management of surgical problems in the following areas of primary responsibility:
Many terms have been used to describe laparoscopic surgery including endoscopic surgery, keyhole surgery and minimally invasive surgery. A common misconception is that this is "laser surgery". However, no lasers are involved.
Laparoscopic surgery is abdominal surgery performed using only ˝ inch or less incisions. Instead of having his or her hands in the belly, the surgeon operates using long hand held instruments that slide in and out of sheaths (trochars) going through the abdominal wall.
To begin, the abdomen is inflated to a constant pressure with CO2 gas. This makes room for visualization of the abdominal cavity using a rigid scope which transmits the image to monitors in the operating room. Specialized tools such as scissors, dissectors, graspers, ultrasonic shears and endoscopic staplers facilitate the surgeon's ability to perform complex intraabdominal surgery.
We among others have been able to master advanced laparoscopic techniques such as major vessel division, suturing and tying and intracorporal anastomosis (reconnecting the bowel without bringing it out of the abdomen).
Laparoscopic abdominal surgery can be used in place of almost all open operations with equal or better results, giving patients less pain and a shorter recovery. There are also smaller scars and less wound complications. In experienced hands, there are few disadvantages, although laparoscopic cases may take longer. However, not all general surgeons do complex laparoscopic surgery.
We were trained in advanced laparoscopic surgery and have made this type of surgery a primary focus of our practice.
This includes common procedures such as removal of the gallbladder or appendix as well as rare cases like splenectomy, small bowel resection and mesenteric lymph node biopsy. We have done hundreds of laparoscopic ventral and inguinal hernia repairs and will suggest this when we feel it is the best for the patient.
For laparoscopic colon resection, the incisions keep getting smaller, and the hospital stay shorter. Using intracorporal anastomosis for both right and left colectomy, we are able to keep the largest incision under two inches. Laparoscopic colectomy is now the standard for both benign disease like polyps or recurrent diverticulitis, and malignant tumors.
With traditional laparoscopic surgery, doctors operate through smaller incisions, using long-handled instruments and a tiny camera (endoscope) or similar device. But, laparoscopic surgery has inherent limitations, particularly for very complex and delicate operations due to the instruments used.
If you are facing surgery, you may be a candidate for a safe, effective and minimally invasive procedure – da Vinci Robotic Surgery. Using the most advanced technology available, the da Vinci System enables your doctor to perform this delicate operation with breakthrough vision, precision and control. da Vinci Robotic Surgery offers patients many potential benefits over traditional surgery, including:
da Vinci Surgery also offers patients the potential for a shorter hospital stay when compared to traditional laparoscopic surgery.
This procedure is performed using the da Vinci Surgical System, a state-of-the-art surgical platform. By overcoming the limits of both traditional open and laparoscopic surgery, da Vinci is changing the experience of surgery for people around the world.
Breast cancer is the leading cause of death among American women between the ages of 40 and 55. Breast cancer affects about one in nine women. However, certain women are in high risk groups and have a greater incidence. The greatest risk occurs in those who have a first degree relative with breast cancer, especially if she was younger than 50 years old when diagnosed, and in those who have a history of breast cancer in one breast.
Breast cancer requires a multidisciplinary approach to its diagnosis and management, with primary care physicians, radiologists, surgeons, radiation oncologists, and medical oncologists playing a role. Baseline screening mammography should be performed in all women between the ages of 35 and 40. Mammography is recommended every two years until age 50 and then yearly.
This should be accompanied by a physical examination as about 15% of cancers will be palpable but not show up on the mammogram. More importantly, every woman should perform self breast examinations monthly. She is more likely to detect a breast lump at an early stage.
The definitive diagnosis is made by biopsy, either by needle aspiration or open excision, and this is performed by the surgeon. Thus any patient with an abnormal mammogram or palpable breast lump should receive surgical consultation. We frequently perform needle biopsy in our office. However, many times there is only a mammographic abnormality which cannot be palpated. This requires radiographic localization, followed by excision.
A newer technique of steriotaxic needle biopsy may be employed in many cases as a less invasive modality to get a diagnosis. This is performed by the radiologist using X-ray guided needle biopsy. Once the diagnosis is made, metastatic disease should be ruled out by blood tests, chest X-ray, and possibly CAT scan or bone scan for symptomatic patients.
The next step is surgical removal of the cancer and staging of the axillary (under arm) lymph nodes. The current trend is toward breast conservation therapy. This involves lumpectomy (removing the cancer with some surrounding normal breast tissue) and radiation to the breast. We also perform sampling of the axillary lymph nodes using sentinel lymph node biopsy. This state of the art technique allows us to find the one or two nodes which are in direct communication to the cancerous region of the breast.
These nodes are examined by the pathologist at the time of surgery, and if they are negative, the rest of the lymph nodes are left in place. This avoids unnecessary removal of all the lymph node tissue and helps to decrease complications, such as arm swelling. All of our surgeons are skilled at breast conservation therapy and sentinel lymph node biopsy. We make a special effort to see patients with suspected breast cancer emergently, and move rapidly to make a diagnosis and if necessary, perform definitive surgery.
As our expertise has grown and instrumentation has improved, we have adopted techniques of intracorporal (inside the abdomen) anastomosis, which allows the surgery to be completed with incisions no larger than two inches. We have found that this is more cosmetic and decreases hospital stay to 2-3 days.
Intracorporeal anastomosis produces superior results with shorter length of stay, decreased postoperative narcotic use, faster return of bowel function, and decreased morbidity. Many general and colorectal surgeons do laparoscopic colon surgery with or without hand assistance and use much larger incisions.
The formation of stones in the gallbladder is very common in Americans. It is partially due a high cholesterol diet and other intrinsic factors. Approximately 50% of Americans have gallstones but most people are not aware they have them until they have a complication related to the stones. The most common is an attack of right upper abdominal pain. We call this biliary colic. The attacks usually start 30 to 60 minutes after eating. Once one has an attack, he or she will most likely continue to have problems until the gallbladder is removed.
If the stones block the gallbladder duct (cystic duct) this can lead to an infection of the gallbladder or acute cholecystitis. The symptoms are right upper abdominal pain, fever, vomiting and tenderness. This necessitates admission to the hospital, antibiotics, and removal of the gallbladder. If the stones pass into the common bile duct, they can cause jaundice as well as pain and infection. If the stones pass, they can cause a back up of pancreatic secretions causing pancreatitis.
The diagnostic study of choice to identify gallstones and gallbladder infection is an ultrasound, which is a noninvasive radiological scan. If you experience upper abdominal pain on the right side, especially after you eat, you may want to consult your physician about ordering an ultrasound.
Once a person has a gallbladder attack, and an ultrasound documents gallstones, we recommend elective removal of the gallbladder using the laparoscopic technique. We are all very experienced and skilled in this technique, as it is one of the most common procedures that we perform. The recovery is much shorter with laparoscopy, with a return to normal activities and work expected in one week or less. A one night stay in the hospital is usual.
Less than 10% of the time, patients may experience typical upper abdominal pain and have a negative ultrasound. Other causes of this type of pain include ulcers and gastritis. A dysfunction of the gallbladder contracting mechanism, called Biliary Dyskinesia has been identified as another common cause of this pain syndrome. This diagnosis can be made by a nuclear scan called a CCK-HIDA scan. If the scan is positive, laparoscopic removal of the gallbladder is indicated to relieve the pain and prevent future episodes.
Gastrointestinal surgery is the largest portion of our practice, thus we have extensive experience in this area. We have performed hundreds of operations on the stomach, small intestine, gallbladder and colon for both infectious and malignant disease. For both emergency and elective abdominal surgery, our group leads the way in accurate diagnosis and surgical treatment with low complication rates and excellent outcomes.
The most common diseases of the gastrointestinal tract that we treat are:
Abdominal wall hernias are common in humans and result from a breakdown of the supporting tissue, called fascia. A “hole” forms in the abdominal wall and this causes a cosmetic bulge and sometimes pain. When hernias enlarge, there is significant loss of abdominal wall support. In addition, small intestine can squeeze into the hole and become stuck or “incarcerated”. Therefore, hernias are one of the most common causes of bowel obstruction and may lead to intestinal strangulation. This is a severe life-threatening condition requiring emergency surgery.
Furthermore, once hernias start, they never go away on their own. They only get larger over time due to intra-abdominal pressure. Therefore, it is standard surgical care to repair hernias electively when they are diagnosed. Due to overwhelming evidence that tension free mesh repairs offer significantly lower recurrence rates, prosthetic mesh is used in nearly all hernia surgery, and has been for almost 25 years.
When people think about skin surgery, they usually think of dermatologists or plastic surgeons. However, as general surgeons, we evaluate and treat diseases of the skin and soft tissue almost every day. Our areas of expertise include evaluation and diagnosis of pigmented lesions, soft tissue masses, traumatic tissue injury, infections, and pressure ulcers.
We obtain a thorough history and physical exam during an office consultation and make a decision on further management. Pigmented lesions that are new, enlarging or bleeding can be worrisome. On the exam, we are more suspicious if the lesion has black color, irregular boarders, ulceration, and size greater than 6 mm.
Obviously benign lesions may be observed or excised based on patient preference. For suspicious or indeterminate lesions, we have a variety of biopsy techniques available in our office under local anesthesia, including shave biopsy, full thickness punch biopsy and full thickness excisional biopsy.
If a patient has a postitive biopsy for malignant melanoma, we stage the disease based on the thickness of invasion. If it is less than 1 mm thick, it is considered stage I which has a very low chance of metastasizing to lymph nodes. The treatment is a wide local excision with a one centimeter margin. This is an outpatient surgery at the hospital under twilight anesthesia. If the primary lesion has a depth of invasion 1 to 4 millimeters, it is considered intermediate thickness and does have a chance for lymph node metastasis. Thus, we recommend a sentinel lymph node biopsy. This technique allows analysis of one or two lymph nodes in the Axilla or groin. If negative, the patient is spared the morbidity of a complete lymph node dissection.
Soft tissue tumors may represent lymph nodes, congenital cysts or benign or malignant neoplasms such as sarcoma or metastatic disease. We question patients regarding how long they have had the lesion, if it is growing, if it is painful or has ever been infected. We ask about personal or family history of malignancy. The examination focuses on skin changes, size of the lesion, weather it is fixed to the muscle and the consistency.
The initial options include imaging by ultrasound or MRI, needle biopsy or excisional biopsy. The decision is based on suspicion of malignancy. If a patient has a small superficial tumor that is stable, it can be watched. Deeper masses are usually imaged with MRI as a first step. It is not usual to perform a needle biopsy unless the lesion is thought to be a lymph node. Therefore, If it has reached a large size, is rapidly growing, is hard or fixed to the muscle, it should be removed for diagnosis and treatment. All specimens are sent for pathologic analysis. If a malignancy is diagnosed, it is sometimes necessary to perform another more radical surgery, with or without the addition of chemotherapy or radiation, depending on the diagnosis.
Our full thickness excision method involves two layer skin closure using absorbable suture. This plastic surgical technique leads to minimal scarring and increased patient satisfaction.
Treatment of skin infections, ulcers and varicose veins rounds out our expertise. We provide urgent service to patients with skin and soft tissue infections. If a patient calls our office with a boil or severe infection we will work them in the same day for evaluation and incision and drainage when necessary. Many times, the wound is left open to heal from the bottom up. We see all our patients through the wound care process. If someone needs inpatient care, we are readily available to provide this.
"Surgical Oncology" refers to surgery for cancer. As board certified general surgeons, we are trained in nearly all major organ resections for cancer. In addition, we are aware of the options for chemotherapy and radiation therapy and whether they should be given before or after the operation. We work closely with medical and radiation oncologists to provide you with optimal care.
Evaluation of patients with thyroid nodules is an important part of our practice. We perform fine needle aspiration biopsy of thyroid nodules in the office, as this is the procedure of choice for making the diagnosis.
About 20% of these nodules will be malignant or suspicious for malignancy and these will require surgical removal of the affected thyroid lobe. If cancer is found, total thyroidectomy is usually necessary.
We also evaluate and treat patients with elevated calcium levels and hyperparathyroidism. We are able to take advantage of the newest trend in endocrine surgery, which involves the use of a rapid parathyroid hormone assay intraoperatively while performing a neck exploration for hyperparathyroidism.
Serum levels are taken at the start of the operation and then again 5 and 10 minutes after the removal of an enlarged gland. The level should fall by greater than 50%, signifying that the offending adenoma has been removed. If the level does not decrease, it may indicate a double adenoma or four gland hyperplasia, thus the surgeon would proceed with further exploration.
This allows the surgeon to achieve a higher success rate than with "blind" removal of parathyroid glands.