Anthony C. Watkins

Using GoPro to Give Video-Assisted Operative Feedback for Surgery Residents: A Feasibility and Utility Assessment

OBJECTIVE As an adjunct to simulation-based teaching, laparoscopic video-based surgical coaching has been an effective tool to augment surgical education. However, the wide use of video review in open surgery has been limited primarily due to technological and logistical challenges. The aims of our study were to (1) evaluate perceptions of general surgery (GS) residents on video-assisted operative instruction and (2) conduct a pilot study using a head-mounted GoPro in conjunction with the operative performance rating system to assess feasibility of providing video review to enhance operative feedback during open procedures. DESIGN GS residents were anonymously surveyed to evaluate their perceptions of oral and written operative feedback and use of video-based operative resources. We then conducted a pilot study of 10 GS residents to assess the utility and feasibility of using a GoPro to record resident performance of an arteriovenous fistula creation with an attending surgeon. Categorical variables were analyzed using the chi-square test. SETTING Academic, tertiary medical center. PARTICIPANTS GS residents and faculty. RESULTS A total of 59 GS residents were anonymously surveyed (response rate = 65.5%). A total of 40% (n = 24) of residents reported that structured evaluations rarely or never provided meaningful feedback. When feedback was received, 55% (n = 32) residents reported that it was only rarely or sometimes in regard to their operative skills. There was no significant difference in surveyed responses among junior postgraduate year (PGY 1-2), senior (PGY 3-4), or chief residents (PGY-5). A total of 80% (n = 8) of residents found the use of GoPro video review very or extremely useful for education; they also deemed video review more useful for operative feedback than written or communicative feedback. An overwhelming majority (90%, n = 9) felt that video review would lead to improved technical skills, wanted to review the video with the attending surgeon for further feedback, and desired expansion of this tool to include additional procedures. CONCLUSIONS Although there has been progress toward improving operative feedback, room for further improvement remains. The use of a head-mounted GoPro is a dynamic tool that provides high-quality video for operative review and has the potential to augment the training experience of GS residents. Future studies exploring a wide array of open procedures involving a greater number of trainees will be needed to further define the use of this resource.

Transabdominal robotic repair of a congenital right diaphragmatic hernia containing an intrathoracic kidney: a case report

Bochdalek diaphragmatic hernia is a rare condition and is typically diagnosed prior to adulthood. Furthermore, right-sided defects are also uncommon due to the location of the liver, but can contain colon, omentum, small bowel, or rarely the kidney. Minimally invasive laparoscopic and thoracoscopic diaphragmatic hernia repairs are associated with improved outcomes when compared to open approaches—recently, robotic-assisted repairs have been performed in children with no morbidity and minimal complications. We report a case of an 80-year-old female who presented with an enlarging right-sided Bochdalek hernia containing an acquired intrathoracic kidney that was repaired using a robotic-assisted laparoscopic transabdominal approach with mesh placement. In this case, the robotic platform’s advantages included excellent visualization of the posterolateral defect and efficient suturing during mesh placement. This approach is a viable option for skilled minimally invasive surgeons; however, further studies are warranted to investigate its utility in the management of diaphragmatic hernia repair.

Renal allograft outcomes following early corticosteroid withdrawal in Hispanic transplant recipients

Renal transplant outcomes in Hispanics have been conflicting regarding acute rejection (AR) and allograft survival. Additionally, the feasibility of early corticosteroid withdrawal (ECW) regimens among Hispanics has not been adequately addressed. The purpose of this study is to report outcomes following ECW among Hispanic renal transplant recipients.

Racial and ethnic disparities in promotion and retention of academic surgeons

BACKGROUND Racial/ethnic diversity remains poor in academic surgery. However, no study has quantified differences in the rates of retention and promotion of underrepresented minority (URM) academic surgeons. METHODS The American Association of Medical Colleges Faculty Roster was used to track all first-time assistant and associate professors appointed between 1/1/2003 and 12/31/2006. Primary endpoints were percent promotion and retention at ten-year follow-up. RESULTS Initially, the majority of assistant and associate professors of surgery were White (62%; 75%). Black assistant professors had lower 10-year promotion rates across all specialties (p < 0.01). There were no race/ethnicity-based differences in promotion for associate professors. Retention rates were higher for White assistant professors than Asian or Black/Hispanic/Other minority faculty (61.3% vs 52.8% vs. 50.8% respectively; p < 0.01). There was no difference in 10-year retention rates among associate professors based on race/ethnicity. CONCLUSIONS Underrepresented minority surgeons are less likely to remain in academia and Black assistant professors have the lowest rates of promotion. These findings highlight the need to develop institutional programs to better support and develop minority faculty members in academic medicine.

Kidney Allograft Failure in the Steroid-Free Immunosuppression Era: A Matched Case-Control Study

We studied the causes and predictors of death‐censored kidney allograft failure among 1670 kidney recipients transplanted at our center in the corticosteroid‐free maintenance immunosuppression era. As of January 1, 2012, we identified 137 recipients with allograft failure; 130 of them (cases) were matched 1‐1 for recipient age, calendar year of transplant, and donor type with 130 recipients with functioning grafts (controls). Median time to allograft failure was 29 months (interquartile range: 18‐51). Physician‐validated and biopsy‐confirmed categories of allograft failure were as follows: acute rejection (21%), glomerular disease (19%), transplant glomerulopathy (13%), interstitial fibrosis tubular atrophy (10%), and polyomavirus‐associated nephropathy (7%). Graft failures were attributed to medical conditions in 21% and remained unresolved in 9%. Donor race, donor age, human leukocyte antigen mismatches, serum creatinine, urinary protein, acute cellular rejection, acute antibody‐mediated rejection, BK viremia, and CMV viremia were associated with allograft failure. Independent predictors of allograft failure were acute cellular rejection (odds ratio: 18.31, 95% confidence interval: 5.28‐63.45) and urine protein ≥1 g/d within the first year post‐transplantation (5.85, 2.37‐14.45). Serum creatinine ≤1.5 mg/dL within the first year post‐transplantation reduced the odds (0.29, 0.13‐0.64) of allograft failure. Our study has identified modifiable risk factors to reduce the burden of allograft failure.

Surgical Management of the Kidney Transplant Recipient

The early postoperative course and management can have a significant impact on the longterm success of a kidney transplant recipient. Several factors affect long-term outcomes including the occurrence of delayed graft function (DGF), episodes of acute rejection (AR), surgical complications, and overwhelming infections, especially sepsis [1-3]. Certain medications, including calcineurin inhibitors (CNI), also have potential for nephrotoxic effects, which can later lead to transplant glomerulopathy [4]. Furthermore, recipient characteristics, such as sensitization status, and donor characteristics, such as donation after cardiac death (DCD) donors and expanded criteria donors (ECD) can all affect long-term outcomes [5]. Although basic postoperative surgical principles are applied, there are certain parameters that need to be closely monitored, especially as it pertains to fluid management, blood pressure control, and immunologic status. Early detection of graft dysfunction is paramount in determining reversibility from both medical and surgical complications. Recognizing the technical limitations during surgery can also help prevent potentially devastating mechanical complications. Thus, appropriate initial management and mitigation of various risk factors is extremely important in the long-term success of the kidney transplant patient.

Expanding Opportunities for Kidney Transplantation

Despite the increased use of living donors and marginal donor kidneys, there still exists a significant discrepancy between the organ supply and demand in renal transplantation [1]. This has led to excessive waiting times affecting patient survival. More than half of all patients with end-stage renal disease (ESRD) over the age of 60 die before receiving a kidney transplant [2]. These patients face a mortality rate of 6% per year while awaiting an acceptable donor. Thus, transplant surgeons and physicians have turned to other potential sources of allografts to meet the ever growing demand. Potential resources include maximizing the utilization of pediatric donors, increasing use of marginal donors, and transplanting hepatitis C (HCV) positive donor kidneys into HCV positive recipients. Finally, the advent of kidney paired donation has significantly improved and maximized the use of living donor renal transplants.