University Suburban is a collection of offices for the elite of University Hospitals of Cleveland Surgeons, none of whom can diagnose ACNES = abdominal cutaneous nerve entrapment syndrome. The most common cause of abdominal wall pain is NERVE ENTRAPMENT AT THE LATERAL BORDER OF THE RECTUS MUSCLE. There is a physical exam for this, but none of the surgeons at Suburban do it or consider the diagnosis. If you try to leave the article for Thomas Stellato MD – the Medical Director – the guy who makes up the Board Questions for the Boards of General Surgery and the Review Materials, he calls the South Euclid Police Department without reading the article. Stellato can’t be bothered – and that’s been the problem with communicating with him for a long time. The best article on this commonly misdiagnosed cause of abdominal wall pain is at http: / / xnet.kp.org / permanentejournal / sum02 / acnes.pdf, or just google ACNES. If patients keep handing it to Dr. Stellato, maybe he’ll read it and get the message (as in the Jason Mraz song). As the Medical Director, he’s responsible for educating the rest of the staff as to common problems that get misdiagnosed. Dr. Stellato will try to schedule surgeries for this, and surgeries to remove old prolene sutures, without doing the physical exam for the neuromuscular foramen – from T8 to T-12 / L-1 levels. Even when he’s in the incision directly, he does not check these areas – and abdominal pain can be multifactorial & complicated. All surgeons should be familiar with the exact location of each abdominal neuromuscular foramen. No excuses – the diagram in the article can be copied and included in the surgical chart. It should be part of a surgical checklist. There are 5 commonly affected foramen on each side of the lateral rectus muscle, and the patient will usually point to the site of pain with one finger, on one side of the abdominal wall rectus muscle border. Each time a patient’s abdomen is examined for any reason, the examiner should feel for the anterior openings of each neuromuscular foramen – for herniation, pain, or swelling of the anterior cutaneous nerve branches as it exits the aponeurotic opening on each side. The article by Dr. Applegate on the web has a great picture diagram, which patients can use to tell the surgeon where the pain is. Take it to your local surgeon if you think that this is what you have – and from adolescents to geriatrics, it is a commonly misassessed cause of abdominal pain in Cleveland at University Hospitals. Abdominal wall pain is often wrongly attributed to intra-abdominal disorders, and this leads to unnecessary consultation, testing and even abdominal surgery – all of which can be avoided if the INITIAL examiner make the right diagnosis. The T-11 foramen is affected after appendectomy, the T12-L1 foramen is affected sometimes after Pfannenstiel incisions for C-sections. Bariatric surgeries can probably cause entrapments at multiple levels. But all surgeons should be familiar with the diagnosis and the exam – to save patients unnecessary surgeries. If Dr. Stellato is doing a re-opening of an old incision, he should be able to examine the adjacent foramina for nerve compression / pain directly (keeping the patient under local anesthesia & seeing the pain response) – which would have saved at least one patient more surgery and his anger / frustration. This is not Carol’s fault, but Carol doesn’t answer her phone when a MD patient wants to discuss this possibility with Dr. Stellato. Mayo Clinic doesn’t do any better, and Dr. Michael Rosen at University Hospitals (the hernia guy) also hasn’t got a clue. The problem is in the resident & staff teaching at University Hospitals. Dr. Jeffrey Ponsky has the article, and the residents don’t have a clue. Medical Students this is a way to get Honors. Patients who got unnecessary surgeries should be seen by the Plastics Department at University FREE – to undo the common mass closures and defects from the mistaken assessment of this very common problem – it wasn’t the patient’s fault nor the responsibility of the South Euclid Police Department to threaten patient’s wrongly surgerized. Surgeons will see it first if there is an old incision, and they must be familiar with the physical exam and the recommended treatment – an injection of 2% lidocaine and not a surgical slot. Abdominal wall pain is a common cause of office visits, and wrong surgeries. The University Surgeons need to get on the problem – starting with Dr. Thomas Stellato. It needs to be on the General Surgery Boards and included in the oral questions – as a common cause of abdominal pain without other clinically significant symptoms.
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