Hueylan Chern

Outcomes Analysis of Biologic Mesh Use for Abdominal Wall Reconstruction in Clean-Contaminated and Contaminated Ventral Hernia Repair.

BackgroundRepair of grade 3 and grade 4 ventral hernias is a distinct challenge, given the potential for infection, and the comorbid nature of the patient population. This study evaluates our institutional outcomes when performing single-stage repair of these hernias, with biologic mesh for abdominal wall reinforcement. MethodsA prospectively maintained database was reviewed for all patients undergoing repair of grade 3 (potentially contaminated) or grade 4 (infected) hernias, as classified by the Ventral Hernia Working Group. All those patients undergoing repair with component separation techniques and biologic mesh reinforcement were included. Patient demographics, comorbidities, and postoperative complications were analyzed. Univariate analysis was performed to define factors predictive of hernia recurrence and wound complications. ResultsA total of 41 patients underwent single-stage repair of grade 3 and grade 4 hernias during a 4-year period. The overall postoperative wound infection rate was 15%, and hernia recurrence rate was 12%. Almost all recurrences were seen in grade 4 hernia repairs, and in those patients undergoing bridging repair of the hernia. One patient required removal of the biologic mesh. Those factors predicting hernia recurrence were smoking (P = 0.023), increasing body mass index (P = 0.012), increasing defect size (P = 0.010), and bridging repair (P = 0.042). No mesh was removed due to perioperative infection. Mean follow-up time for this patient population was 25 months. ConclusionsSingle-stage repair of grade 3 hernias performed with component separation and biologic mesh reinforcement is effective and offers a low recurrence rate. Furthermore, the use of biologic mesh allows for avoidance of mesh explantation in instances of wound breakdown or infection. Bridging repairs are associated with a high recurrence rate, as is single-stage repair of grade 4 hernias.

Leukocyte-depleted blood transfusion is associated with decreased survival in resected early-stage lung cancer

OBJECTIVES Blood transfusion has been shown to have deleterious effect on lung cancer survival, but little data are available that assess whether leukocyte-depleted (LD) blood has a similar adverse effect. Our institution has been using LD red cells since 2001. We sought to determine whether LD blood has an effect on survival after resection of early-stage lung cancer. METHODS From a prospective database, we evaluated all patients with pathologic stage I non-small cell lung cancer. Patients receiving LD blood were compared with those receiving no transfusion. Survival was estimated using the Kaplan-Meier method and compared using the log-rank test. Multivariate analysis by Cox regression was used to identify independent risk factors affecting survival. RESULTS From 2001 to 2009, 361 patients were evaluated; 63 received LD red cell cell transfusion and 298 received no transfusion. Median follow-up was 48 months. Disease-free survival (P < .001) and overall survival (P < .001) were worse in patients receiving LD blood. Stratifying for stage, disease-free survival continued to be worse with transfusion for stage IA (P = .002) and IB (P = .002). Similarly, overall survival continued to be worse with transfusion for stage IA (P < .001) and IB (P < .001). For disease-free and overall survival, univariate analysis revealed increased age, male gender, anemia, transfusion, and higher stage to be adverse factors, with transfusion and higher stage continuing to be significant adverse factors after multivariate analysis. CONCLUSIONS Our data suggest that transfusion of LD blood is associated with a worse disease-free and overall survival in patients with resected stage I non-small cell lung cancer.

Perineal flap reconstruction following oncologic anorectal extirpation: an outcomes assessment.

Background: The poorly healing perineal wound is a significant complication of abdominoperineal resection. The authors examined criteria for immediate flap coverage of the perineum and long-term cross-sectional surgical outcomes. Methods: Patients who underwent abdominoperineal resection or pelvic exenteration for anorectal cancer were retrospectively analyzed. Demographic characteristics, premorbid and oncologic data, surgical treatment, reconstruction method, and recovery were recorded. Outcomes of successful wound healing, surgical complications necessitating intervention (admission or return to the operating room), and progression to chronic wounds were assessed. Results: The authors identified 214 patients who underwent this procedure from 1995 to 2013. Forty-seven patients received pedicled flaps and had higher rates of recurrence and reoperation, active smoking, Crohn disease, human immunodeficiency virus, and anal cancers, and had higher American Joint Committee on Cancer tumor stages. Thirty-day complication rates were equivalent in the two groups. There were no complete flap losses or reconstructive failures. Perineal wound complication rates were marginally but not significantly higher in the flap group (55 percent versus 41 percent; p = 0.088). Infectious complications, readmissions for antibiotics, and operative revision were more frequent in the flap cohort. A larger proportion of the primary closure cohort developed chronic draining perineal wounds (23.3 versus 8.5 percent; p = 0.025). Conclusions: Immediate flap coverage of the perineum was less likely to progress to a chronic draining wound, but had higher local infectious complication rates. The authors attribute this to increased comorbidity in the selected patient population, reflecting the surgical decision making in approaching these high-risk closures and ascertainment bias in diagnosis of infectious complications with multidisciplinary examination. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

An Objective Assessment Tool for Basic Surgical Knot-Tying Skills

OBJECTIVE To determine if a knot-tying checklist can provide a valid score and if the checklist can be used by novice surgeons in a reliable manner. METHODS This study was conducted at the Surgical Skills Center at the University of California, San Francisco. A knot-tying checklist was developed from a kinesthetic knot-tying curriculum. Novice (67 first-year medical students) and experienced surgeons (8 residents postgraduate year 3 and higher and 2 attending physicians) were videotaped performing 4 knot-tying tasks, and the videotapes were rated with a global score and a checklist by interns (n = 3) and experienced (n = 3) surgeons. RESULTS Both interns and experienced surgeons can use the knot-tying checklist with acceptable reliabilities (>0.8 with 3 raters). The checklist is able to differentiate between novice and experienced surgeons, when used by both interns and experienced raters. The expert knot-tying score correlated with the global score overall (r = 0.88) and for each task (r was 0.82 for task 1, 0.85 for task 2, 0.80 for task 3, and 0.81 for task 4). CONCLUSIONS The knot-tying checklist provides a valid score for basic surgical knot-tying and can be used by novice and experienced raters. Its use supports peer assessment of performance in a surgical skills laboratory setting.

Current robotic curricula for surgery residents: A need for additional cognitive and psychomotor focus

BACKGROUND Current robot surgery curricula developed by industry were designed for expert surgeons. We sought to identify the robotic curricula that currently exist in general surgery residencies and describe their components. METHODS We identified 12 residency programs with robotic curricula. Using a structured coding form to identify themes including sequence, duration, emphasis and assessment, we generated a descriptive summary. RESULTS Curricula followed a similar sequence: learners started with online modules and simulation exercises, followed by bedside experience during R2-R3 training years, and then operative opportunities on the console in the final years of training. Consistent portions of the curricula reflect a device-dependent training paradigm; they defined the sequence of instruction. Most curricula lacked specifics on duration and content of training activities. None clearly described cognitive or psychomotor skills needed by residents and none required a proficiency assessment before graduation. CONCLUSIONS Resident-specific robotic curricula remain grounded in initial industrial efforts to train experienced surgeons, are non-specific regarding the type and nature of hands on experience, and do not include discussion of operative technique and surgical concepts.

Using Technological Advances to Improve Surgery Curriculum: Experience With a Mobile Application

OBJECTIVE Our previous home-video basic surgical skills curriculum required substantial faculty time and resources, and was limited by delayed feedback and technical difficulties. Consequently, we integrated that curriculum with a mobile application platform. Our purpose is to describe this application and learner satisfaction. MATERIALS AND METHODS The mobile platform incorporates a patented pedagogical design based on Ericssons deliberate practice and Banduras social learning theory. Instructors built step-wise skills modules. During the challenge phase, learners watched a video of surgical tasks completed by experts and uploaded a video of themselves performing the same task. In the Peer Review phase, they used a grading rubric to provide feedback. In the Recap stage, learners received individual feedback and could review their own videos. Two groups of learners, graduating medical students and matriculating surgical residents, participated in this independent learning platform, along with 2 to 4 laboratory sessions, and completed a survey about their experience. Survey responses were summarized descriptively and comments analyzed using content analysis. RESULTS Fifty learners submitted videos of assigned tasks and completed peer reviews. Learners reported positive experiences specifically for the Peer Review Stage, structured home practice, ease of mobile access to submit and review videos, and ongoing immediate feedback. Over half of the learners reported spending at least 10 to 30 minute practicing skills before recording their videos and over 80% rerecorded at least 2 times before submission. Content analysis revealed learners engaged with the educational concepts designed into the platform. CONCLUSION Learners easily used and were satisfied with a mobile-technology teaching platform that maintained the fundamental content, educational theories, and organizational structure of our previously effective surgical skills curriculum. Prior challenges were directly addressed through the mobile applications ease of use, support of deliberate practice, and improved timeliness of feedback.

Is Robotic Surgery Highlighting Critical Gaps in Resident Training

I ntegrating robotic surgery into resident training is challenging. The robotic environment requires reconsideration of the apprenticeship model for surgical training and development of new curricula and instructional approaches to ensure skill acquisition. The surgical literature has mentioned the need to improve resident training in robotic surgery. This article highlights components of the robotic teaching environment that limit the efficacy of current training models. By targeting these components, educators can begin to develop more effective curricula and instructional strategies for surgical residents. The robotic learning environment is complex. It incorporates a physically distant operative field, separating the trainer and the trainee; it makes the surgeon less dependent on assistance from a resident; and it necessitates acquisition of perceptual expertise without tactile information. At teaching hospitals, residents are exposed to an increasing number of robotic procedures, yet this often occurs in the context of observers, not participants. This has resulted in an emerging training gap. By considering relevant cognitive learning theories, we can guide surgical educators to new approaches to reduce this gap. While recent literature highlighted the feasibility and safety of implementing robotic curricula in residency, few studies have evaluated their efficacy, or described curricular components in detail. Surgical educators need a deep understanding of the robotic environment to appropriately evaluate the efficacy of resident integration in the operating room. Robotic technology provides independence for surgeons. Using the robot, 1 surgeon controls 4 robotic arms and manipulates the camera independently, decreasing the need for residents as assistants. While beneficial to hospitals with limited staffing, this aspect of robotic surgery presents challenges in teaching settings. Typically, in open or laparoscopic operations, residents obtain technical skills as surgical assistants, providing retraction and tissue manipulation essential for creating a functional operative field. This experience allows learners to understand how the surgeon’s movements (degree of tension or retraction) affect the operative field. Residents stand across from, or adjacent to, the attending surgeon throughout the procedure—often with arms entangled in an effort to create adequate visualization. Residents directly observe the attending physician’s physical movements, including minute details of individual digit placement, while performing each operative step. Robotic surgery technology is entirely different. It creates a physical distance between the operating surgeon, the operative field, and any assistants or learners. Residents are positioned at the bedside assisting with instrument exchange, or seated at a console distant from the sterile operative field. They cannot see the attending’s physical movements, and cannot appreciate when the attending surgeon ‘‘clutches,’’ repositioning the hands, maximizing economy of motion. Residents also are unaware when the attending reaches for the foot pedal to swap robotic arms or activate electrocautery. Residents are limited to observing the movements of the robotic arms, either extracorporeally from the bedside or intracorporeally from a console or monitor. To learn to perform the movements as they appear on the screen, the resident must recreate the movements of the surgeon seated at the console. In contrast, in open and laparoscopic surgery, the operating surgeon’s movements are open and visible. In the robotic environment, the operating surgeon’s movements cannot be fully appreciated. How will residents understand what physical movements on the console are needed to translate into the same observed actions seen on the screen? The frequent experiential instruction that occurs in surgical training becomes complicated by a physically separated operative field (described by Zemel and Koschmann as the combination of instructional demonstration, creation of referential practices, and embodied procedures). DOI: http://dx.doi.org/10.4300/JGME-D-17-00802.1