The most common cause of abdominal wall pain - Anterior Cutaneous [Abdominal] Nerve Entrapment Syndrome (ACNES) - does not require surgery. But it requires a surgeon with a brain - to tell, discern, or elucidate this problem from a surgical problem, and not schedule an unnecessary surgery. The treatment: an injection of 2% lidocaine makes the diagnosis & treats.
This is something that is goofed up from Mayo Clinic, to Cleveland Clinic, to Massachusetts General; General Surgeons don't get abdominal wall pain - how to diagnose, how to treat, the physical exam, the anatomy, the pathophysiology & clinical presentation. This is probably because the surgeons who write about abdominal wall pain do it badly - from Silen to Stellato.
Abdominal wall pain is the most common cause of ABDOMINAL PAIN - muscle spasms can cause this, pregnancy, and sports injuries - abdominal muscle overuse syndromes occur with exercise machines, track, football, soccer, lacrosse, abdominal crunches, yoga, pilates, and that joke of a sport that can still lead to sports injuries - cheerleading.
Carol, Dr. Stellato's secretary, doesn't get the clinical presentation anymore than he does - if you try to say that you need to discuss, Dr. Stellato thinks that you are 'standing him up.' Dr. Stellato needs to get beyond college dating - or beyond cheerleading.
Dr. Stellato has a list of things that he can handle on his PR materials (and he lists a Nurse Practitioner who is more phantom ghost than real): cholecystectomy, bariatrics, etc. Nowhere on the list is abdominal wall pain = the commonest reason that a patient would seek consultation with a general surgeon. Before a patient gets morbidly obese, they get obese and all the nerve exit points are stretched, irritated, and inflamed. This nerve inflammation, if recognized & properly treated, should be reason enough to lose weight in the 'right' hands - it brings the patient to the surgeon before the need for bariatric procedures = a good thing.
Before something goes wrong with the appendix, ovary, or gallbladder - and the Administration at University Suburban is to be faulted for not understanding this - something will go wrong with the abdominal wall. This problem is a gold mine for those able to recognize the problem - and it doesn't involve a scalpel, an anesthesia guy/gal, or a gurney. It requires a brain.
Sports injuries, pregnancies, surgical incisions - you name it - can cause abdominal nerve compression = ACNES. Women, with smaller abdominal walls, develop this problem more than men - and it needs to be differentiated from kidney, bladder, ovarian, gallbladder, stomach, or other - and kept off surgical scheduling until there is an injection - complete relief of pain by an injected anesthetic agent establishes the diagnosis. No one who has trained under Dr. Stellato, as a medical student or resident, has ever seen him do an exam for this, a workup for this, or an injection for this extremely common problem. He's missed all of these cases for 64 years of living - unable to see an abdominal wall that doesn't need an incision, or another incision, he will call the South Euclid Police to remove these patients. Carol is in on the problem in a big way - she's a complete dufus when speaking to a woman MD, or a patient with abdominal wall pain. But the bigger dufus is Dr. Stellato.
Dr. Stellato doesn't have a code to bill for this injection or exam. The diagnosis requires an injection, NOT AN OR. Which is why Carol has a problem with this - she can't get her head around abdominal wall pain that does not involve a surgery. She can't communicate to Dr. Stellato, and Dr. Stellato doesn't discuss with women MDs. It's like playing 'telephone' with the old Campbell's soup cans - nothing is said that is intelligible.
Each time a patient's abdomen is examined for any reason, the examiner should feel for the anterior abdominal wall aponeurotic nerve openings, easily palpable except in obese patients. This exam is never done.
Surgeons have to avoid these openings when making incisions - so they have to be diagrammed on the physical exam abdominal wall picture - prior to surgery. This documentation has to be done by all surgeons: from Dr. Ponsky, to Dr. Stellato, to Dr. Rosen - and none of them do this so all of them miss this benign cause of abdominal wall pain, and they all cause problems with incisions that cut nerves, or damage the anterior abdominal wall nerves.
Dr. Stellato does this with regular statistical predictability, and the others do also. There isn't a General Surgeon in Cleveland that doesn't cause this problem with misplaced incisions or damage during the procedure (as they don't know what they are feeling). Dr. Stellato never goes into a procedure and palpates these openings directly to make sure that they are not part of the abdominal pain problem. They should be felt before any appendectomy.
There are 10 openings that classically can cause localized pain along the lateral rectus muscles: T-8, T-9, T-10, T-11, and T-12/L-1. You can find cartoons with these illustrated on the web. And as Dr. Stellato reads my 'Ripoff Reports,' but doesn't want to discuss, they are listed here.
There's no Chief of Surgery that currently teaches this exam, but the problem starts in the Review Materials for the Boards of General Surgery - review materials that Dr. Stellato is responsible for, review materials that are minus entities that women get more than male patients. If Dr. Stellato had diagrammed these nerve exists before surgery, he wouldn't miss all the ACNES nerve problems that occur after his surgeries. And the women MDs wouldn't be 'standing him up' in the OR to try to discuss. There isn't an intern or resident at UH that knows how to do the exam, ditto Mayo Clinic and Akron General. Cleveland Clinic ignores the problem - they just deal with HEARTS.
Dr. Stellato doesn't appear to have the ACNES brain - and ACNES is nowhere on the Boards of General Surgery questions. Despite being the most common cause of abdominal wall pain, and the most commonly overlooked cause of abdominal wall pain, almost everyone who has written about abdominal wall pain overlooks this diagnosis - including him - something that he has contributed to. Dr. Stellato has contributed big-time to the SINKHOLE in the literature on this problem.
Everyone misses the diagnosis, including him, because he doesn't put it in the Review Materials for the Boards of General Surgery. And University Suburban doesn't put this problem on the coding list for abdominal wall problems - so it doesn't get diagnosed or treated properly - and Administrative gaffe. If you can't bill for it, you can't diagnose it - or so the mantra goes. The Billing people start the problem.
Carol, Dr. Stellato's secretary, hasn't a clue what this is to put on the office sheets, scheduling, the billing sheets, or to answer questions about it. Carol has just graduated to being able to do a BP check - which is not the major problem or diagnostic dilemma of a General Surgeon's office. Maybe if she knew how to listen to abdominal wall pain symptoms things wouldn't be so screwed up, but she has no medical training.
Then Dr. Stellato can't repair the botched surgeries for this problem: Mayo Clinic will take and cut the muscle fascias to remove the normal nerve. Dr. Stellato should be able to repair muscle fascias, but he apparently doesn't list that on his 'do' list either. Repairing muscle fascia is what every surgical closure is basically in General Surgery - but he can't do this repair? Having missed being conservatively helpful, he can't be surgically helpful.
Dr. Stellato, and University Suburban, need to improve things so that abdominal walls are examined properly - for all patients from professional MDs to dirt-bags. Dr. Stellato needs to put these nerve foramina exams/locations on his office charts, and to learn to treat conservatively - which Carol should have a code for as Kaiser treats this diagnosis in clinics in bulk.
Dr. Stellato pretending that he can't repair abdominal wall fascia in layers, while protesting that he should have gotten the Chief of Surgery nod at University Hospitals, is hypocritical. What do Chiefs of Surgery do besides abdominal wall pain, fascias, and abdominal wall pain. The criteria for the Chief of General Surgery at University Hospitals should be to be able to teach this problem - and none of them can - that includes Mr. Hernia Dr. Rose - who thinks that you have to open women up to tell this problem. If the pain goes away with the injection, it wasn't a suture or a neuroma, it was ACNES. You don't need the OR Dr. Rosen, and $250 an office visit is a bit much for someone to teach you this concept.
Chiefs of Surgery, and the art of surgery, means that you do the proper exam, do the differential, and do only what needs to be done with aesthetics while treating the patient with dignity & respect. Not doing the exam, missing the diagnosis, and calling the South Euclid Police Department to threaten the patient is not respectful, necessary, or standard of care for ACNES. It's surgical bullshit - the pretend of being a surgeon.
Dr. Stellato should not have been missing this problem from 1990-2013. There's no indication that University Suburban has improved the diagnosis, treatment, exam, or even obtained the correct billing codes for the treatment (an injection of 2% lidocaine). It does not involve a trip to Wright Surgery Center, unless the patient had to go to Mayo Clinic and be cut up - needing a fascial repair. And Dr. Stellato's office notes should have gone to Mayo Clinic on that case - with the nerve foramina diagrammed - so that he could have seen that one of the foramina was inflammed by the chart.
None of this missed diagnosis, or botched treatment of it, belongs in the South Euclid Police Department. Because Dr. Stellato didn't do the studying of the problem, didn't incorporate ACNES into the General Surgery Boards materials, and couldn't discuss with any of the list of women patients that he missed this on - none of that is the fault of the South Euclid Police Department. That's Administrative malpractice of the grossest kind - can't find the billing codes, call the police department?
The Administration, and the Medical Director, at University Suburban Health Center needs to attack this overlooked cause of abdominal pain with improved triage, improved documentation, and improved treatment - getting the correct billing codes from Kaiser would be a start, having an in-service from a Kaiser physician would be the next step, and Dr. Stellato apologizing to the women patients that he has 'slammed' is the last step.
No one wants to disagree with Dr. Stellato - as you will probably lose as a woman MD - but patient care of this entity needs to improve starting with Dr. Stellato - before it gets to Ponsky & Rosen. Dr. Stellato needs to see the WIZARD OF OZ and get a brain that has neural circuits for ACNES. Women patients are 'half the sky.'