Abstract Background Considerable resources have been invested in low- and high-fidelity simulators in surgical training. To our knowledge, no investigation has compared the 2 head to head for ...operative assessment purposes. The purpose of this study was to assess the Fundamentals of Laparoscopic Surgery (FLS) low-fidelity video trainer and LapVR (high-fidelity virtual-reality simulator) for (1) construct and (2) predictive validity using a human cholecystectomy model. Methods Twenty-six participants performed tasks from the FLS program and the LapVR simulator as well as a human laparoscopic cholecystectomy. Performance was evaluated using FLS and LapVR metrics and the Objective Structured Assessment of Technical Skills previously validated rating scale. Results Construct and predictive validity were strongly demonstrated for FLS tasks but only incompletely for LapVR. Conclusions Efforts should be focused on using the well-validated lower-cost FLS video trainer for assessment of laparoscopic skills. The high-cost LapVR remains experimental in resource-constrained training programs.
The operative report is vital for patients and central to surgical quality assessment. Narrative operative reports are often poor quality. Synoptic reporting can improve documentation. The objective ...was to identify and appraise studies comparing synoptic and narrative operative reporting.
A systematic review of the literature was performed. The primary outcome was completion of critical elements for an operative report. Additional secondary outcomes were measured. Meta-analysis was performed where possible. Quality analysis was performed using Newcastle-Ottawa Scale (NOS).
1471 citations were identified; 16 studies included. Mean NOS was 7.09 out of 9 (+/−- SD 1.73). Meta-analysis demonstrated that synoptic reporting was significantly more complete (SMD 1.70, 95% CI 1.13 to 2.26; I2 98%). Completion time was shorter with synoptic reporting (mean difference −0.86, 95% CI -1.17 to −0.55). Secondary outcomes favoured synoptic reporting.
Synoptic reporting platforms outperform narrative reporting and should be incorporated into surgical practice.
•Surgical safety and quality of care improvements may be enhanced with synoptic operative reporting.•Systematic review and meta-analysis comparing synoptic versus narrative operative reporting.•Synoptic operative reporting significantly outperforms the narrative format in completeness.•Operative report completion time was significantly shorter with synoptic reporting.•Efficiency and cost effectiveness measures favour synoptic reporting.
Infantile hemangiomas can cause significant morbidity during proliferation, yet there is no U.S. Food and Drug Administration-approved treatment. They are believed to form from hemangioma stem cells, ...which differentiate toward a hemangioma endothelial cell phenotype. Recently, propranolol has demonstrated effectiveness in treating complicated infantile hemangiomas. The authors hypothesize that propranolol facilitates their involution by altering cellular behavior in both hemangioma endothelial and stem cells.
Hemangioma endothelial and stem cells were isolated from resected infantile hemangioma specimens. Cells were treated with 100 μM propranolol for 48 hours, and apoptosis was determined by the presence of annexin V antibody. Proliferation of stem and endothelial cells was assessed after treatment with 50 or 100 μM propranolol or vehicle, for 72 and 96 hours, respectively. Adipogenesis was induced in stem cells with and without propranolol. Pro-adipogenic genes PPARδ, PPARγ, C/EBPα, C/EBPβ, C/EBPδ, RXRα, and RXRγ were analyzed by quantitative polymerase chain reaction.
Annexin V levels were increased in propranolol-treated endothelial cells but not in stem cells. Proliferation of stem and endothelial cells was inhibited by propranolol in a dose-dependent manner. Propranolol-treated stem cells demonstrated accelerated adipogenesis when compared with untreated controls. Transcript levels of C/EBPβ (p < 0.05), RXRγ (p < 0.05), and PPARγ (p < 0.02) were significantly increased when treated with 50 or 100 μM propranolol; and C/EBPδ (p < 0.05), RXRα (p < 0.05), and PPARδ (p < 0.01) transcripts were increased when treated with 100 μM propranolol. C/EBPα transcript levels remained unchanged at either dose.
Propranolol increased apoptosis of hemangioma endothelial cells, but not stem cells, and accelerated adipogenesis of hemangioma stem cells. Thus, propranolol likely accelerates involution to fibrofatty residuum.
Little evidence within plastic surgery literature supports the precept that longer operative times lead to greater morbidity.
The authors investigate surgery duration as a determinant of morbidity, ...with the goal of defining a clinically relevant time for increased risk.
A retrospective chart review was conducted of patients who underwent a broad range of complex plastic surgical procedures (n = 1801 procedures) at UT Southwestern Medical Center in Dallas, Texas, from January 1, 2008 to January 31, 2012. Adjusting for possible confounders, multivariate logistic regression assessed surgery duration as an independent predictor of morbidity. To define a cutoff for increased risk, incidence of complications was compared among quintiles of surgery duration. Stratification by type of surgery controlled for procedural complexity.
A total of 1753 cases were included in multivariate analyses with an overall complication rate of 27.8%. Most operations were combined (75.8%), averaging 4.9 concurrent procedures. Each hour increase in surgery duration was associated with a 21% rise in odds of morbidity (P < .0001). Compared with the first quintile of operative time (<2.0 hours), there was no change in complications until after 3.1 hours of surgery (odds ratio, 1.6; P = .017), with progressively greater odds increases of 3.1 times after 4.5 hours (P < .0001) and 4.7 times after 6.8 hours (P < .0001). When stratified by type of surgery, longer operations continued to be associated with greater morbidity.
Surgery duration is an independent predictor of complications, with a significantly increased risk above 3 hours. Although procedural complexity undoubtedly affects morbidity, operative time should factor into surgical decision making.
Abstract Background Laparoscopic surgery entails a unique skill set, but it is unclear whether it requires a specific assessment form or whether more general assessment tools can be applied. The ...purpose of this study was to assess the concurrent validity of 2 previously validated assessment scales. One scale designed specifically to assess laparoscopic skills and the other to assess more general surgical skills. Methods Postgraduate year 1–6 general surgery and urology residents (n = 33) performed a live laparoscopic cholecystectomy. Three surgeon raters scored their performance using previously validated objective structured assessment of technical skills (OSATS) and global operative assessment of laparoscopic skills rating scales. Results Pearson's correlation coefficient between global operative assessment of laparoscopic skills and OSATS rating scales was .975 ( P = .01). Conclusions The near total correlation between the 2 scales questions the need for separate laparoscopic assessment tools, highlighting the real strengths of OSATS, the use of which allows for more consistent nomenclature and standardized skills assessment across surgical platforms.
Background There is wide variation among laparoscopic colon resection techniques, including the approach for mobilization and the extent of intracorporal vessel ligation, bowel division or ...anastamosis. We compared the short-term outcomes of laparoscopic right hemicolectomy (LRHC) with intracorporeal (IA) versus extracorporeal (EA) anastamosis. Methods We retrospectively reviewed all elective laparoscopic right hemicolectomies performed at St. Joseph’s Hospital between January 2008 and September 2009 and compared the demographic, pathologic, operative and outcome data. Results Fifty LRHCs were completed during the study period: 21 IA and 29 EA. The groups were similar in age, sex, body mass index, American Society of Anesthesiologists score, previous laparotomy and preoperative invasive pathology. There was no difference between IA and EA in mean duration of surgery (170 v. 181 min, p = 0.78), estimated blood loss (14 v. 42 mL, p = 0.15), perioperative blood transfusions (5% v. 14%, p = 0.29), in-hospital morbidity (33% v. 41%, p = 0.56), out-of-hospital morbidity (19% v. 31% p = 0.34), emergency department visits (10% v. 17%, p = 0.16) or 30-day readmissions (5% v. 7%, p = 0.75). There was 1 anastamotic leak in each group and no perioperative deaths. Median length of stay was significantly shorter for IA (4 v. 5 d, p = 0.05). There were 6 extraction site hernias with EA and none with IA ( p = 0.026). Conclusion Laparoscopic right hemicolectomy with IA has the advantage of a less hernia-prone Pfannenstiel extraction site, faster recovery and shorter stay in hospital EA.
BACKGROUND:Pulsed electromagnetic fields have been shown to reduce postoperative pain, inflammation, and narcotic requirements after breast reduction and augmentation surgical procedures. This study ...examined whether pulsed electromagnetic field therapy could produce similar results in patients undergoing unilateral transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction, a significantly more complex and painful surgical procedure.
METHODS:In this double-blind, placebo-controlled, randomized study, 32 patients undergoing unilateral TRAM flap breast reconstruction received active or sham pulsed electromagnetic field therapy. Pain levels were measured by using a visual analogue scale; narcotic use and wound exudate volume were recorded starting 1 hour postoperatively. Wound exudates were analyzed for interleukin-1β.
RESULTS:Mean visual analogue scale pain scores were 2-fold higher in the sham cohort at 5 hours and 4-fold higher at 72 hours (p < 0.01), along with a concomitant 2-fold increase in narcotic use in sham patients (p < 0.01). Wound exudate volume was 2-fold higher in the sham cohort at 24 hours (p < 0.01), and mean interleukin-1β concentration in wound exudates of sham patients was 5-fold higher at 24 hours (p < 0.001).
CONCLUSIONS:Pulsed electromagnetic field therapy significantly reduced postoperative pain, inflammation, and narcotic use following TRAM flap breast reconstruction, paralleling its effect in breast reduction patients. Both studies also report a significant reduction of interleukin-1β in the wound exudate, supporting a mechanism involving a pulsed electromagnetic field effect on nitric oxide/cyclic guanosine monophosphate signaling, which modulates the body’s antiinflammatory pathways. Adjunctive pulsed electromagnetic field therapy could impact the speed and quality of wound repair in many surgical procedures.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, I.
Background
The objective of this study was to compare the total hospital cost of laparoscopic (lap) and open colon surgery at a publicly funded academic institution.
Methods
Patients undergoing ...elective laparoscopic or open colon surgery for all indications at the University Health Network, Toronto, Canada, from April 2004 to March 2009 were included. Patient demographic, operative, and outcome data were reviewed retrospectively. Hospital costs were determined from the Ontario Case Costing Initiative, adjusted for inflation, and compared using the Mann–Whitney
U
test. Linear regression was used to analyze the relationship between length of stay and total hospital cost.
Results
There were 391 elective colon resections (223 lap/168 open, 15.4 % conversion). There was no difference in median age, gender, or Charlson score. Body mass index was slightly higher for laparoscopic surgery (27.5/25.9 lap/open;
p
= 0.008), while the American Society of Anesthesiologists score was slightly higher for open surgery. Median operative time was greater for laparoscopic surgery (224/196 min, lap/open;
p
= 0.001). There was no difference in complication rates (21.6/22.5 % lap/open;
p
= 0.900), reoperations (5.8/6.5 % lap/open;
p
= 0.833) or 30-day readmissions (7.6/12.5 % lap/open;
p
= 0.122). Number of emergency room visits was greater with open surgery (12.6/20.8 % lap/open;
p
= 0.037). Operative cost was higher for laparoscopic surgery ($4,171.37/3,489.29 lap/open;
p
= 0.001), while total hospital cost was significantly reduced ($9,600.22/12,721.41 lap/open;
p
= 0.001). Median length of stay was shorter for laparoscopic surgery (5/7 days lap/open;
p
= 0.000), and this correlated directly with hospital cost.
Conclusions
Laparoscopic colon surgery is associated with increased operative costs but significantly lower total hospital costs. The cost savings is related, in part, to reduced length of stay with laparoscopic surgery.
Abstract Background When learning multiple tasks, blocked or random training schedules may be used. We assessed the effects of blocked and random schedules on the acquisition and retention of ...laparoscopic skills. Methods Thirty-six laparoscopic novices were randomized to practice laparoscopic tasks using blocked, random, or no additional training. Participants performed immediate post-tests, followed by retention tests 6 weeks later. Outcomes included previously validated Fundamentals of Laparoscopic Surgery (FLS) and hand–motion efficiency scores. Results Both blocked and random groups had significantly higher FLS and hand–motion efficiency scores over baseline on post-tests for each task ( P < .05) and higher overall FLS scores than controls on retention tests ( P < .01). No difference was seen between the blocked and random groups in the amount of skill acquired or skill retained. Conclusions Both blocked and random training schedules can be considered as valid training options to allow programs and learners to tailor training to their individual needs.
IntroductionObesity and type 2 diabetes mellitus (T2DM) are growing global health concerns associated with significant morbidity, mortality and healthcare expenditures. Due to histories of ...colonisation and contemporary marginalisation, Canada’s Indigenous populations are disproportionately burdened by obesity, T2DM and many other chronic illnesses. Culturally appropriate research on experiences and outcomes of Indigenous patients undergoing bariatric surgery in Canada is scarce. This qualitative study protocol will use a decolonising approach guided by an Indigenous Elder to explore the perspectives and experiences of urban Indigenous Manitobans with respect to T2DM, obesity and bariatric surgery. This knowledge will guide the development and implementation of culturally sensitive bariatric care.Methods and analysisSequential sharing circles (SSCs) and semistructured conversational interviews that have been purposefully designed to be culturally relevant with the guidance of an Indigenous Elder and advisory group (IAG) will be carried out in Winnipeg, Manitoba, Canada. Indigenous adults who are obese (body mass index >35 kg/m2), have T2DM and live in an urban centre will be recruited. Three groups will be investigated: (1) those who have had bariatric surgery; (2) those on the wait list for bariatric surgery and (3) those not associated with a bariatric surgery programme. Each group of 10–12 participants will be guided through a semistructured script led by an Indigenous Elder. Elder-facilitated conversational interviews will also be completed following the SSCs. All content will be audio recorded and transcribed. Thematic analysis will be used to identify emerging patterns using a constructive grounded theory approach.Ethics and disseminationThis study has received ethical approval from the University of Manitoba Health Research Ethics Board. Findings will inform the development and implementation of culturally sensitive programmes at Manitoba’s Centre for Metabolic and Bariatric Surgery. Results will be disseminated in peer-reviewed scientific journals, at obesity and Indigenous health conferences, and knowledge sharing ceremonies.
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