Mary E. Klingensmith

Laparoscopic paraesophageal hernia repair, a challenging operation: Medium-term outcome of 116 patients

Laparoscopic paraesophageal hernia repairs performed in 116 patients between 1992 and 2001 were pro-spectively analyzed. Perioperative outcomes were assessed and follow-up was performed under protocol. There were 85 female and 31 male patients who had a mean (± SD)ageof65 ± 13 years and an American Society of Anesthesiology score of 2.3 ± 0.6. All but two patients underwent an antireflux procedure. Gastropexy was performed in 48 patients, an esophageal lengthening procedure in six patients, and prosthetic closure of the hiatus in six patients. Major complications occurred in five patients (4.3%) with two postoperative deaths (1.7%). Mean follow-up was 30 ± 25 months; 96 patients (83%) have been followed for more than 6 months. Among these patients, 73 (76%) are asymptomatic, 11 (11%) have mild symptoms, and 12 (13%) take antacid medications. Protocol barium esophagograms were obtained in 69% of patients at 6 to 12 months’ follow-up. Recurrence of hiatal hernia was documented in 21 patients (22% overall and in 32% of those undergoing contrast studies). Reoperation has been performed in three patients (3 %). When only the patients with recurrent hiatal hernias are considered, 13 (62 %) are symptomatic but only six (28%) require medication for symptoms. Laparoscopic paraesophageal hernia repair is generally safe, even in this high-risk group. This study confirms a relatively high incidence of recurrent hiatal abnormalities after paraesophageal hernia repair; however, most recurrent hiatal hernias are small and only 3% have required reoperation. Protocol esophagograms detect recurrences that are minimally symptomatic. Improved techniques must be devised to improve the long-term outcomes of laparoscopic paraesophageal hernia repair.

Issues in General Surgery Residency Training—2012

The operations which are done by general surgeons, and the way in which they are done, have undergone radical change during the last 2 decades, yet the impacts on residency training have not been generally recognized. The change has come about because of 2 principal factors—evolutionary and technological changes, which have occurred in the treatment of several common diseases, and the conversion of a major proportion of abdominal surgery from an open to a laparoscopic approach. In addition to the change in the nature of the surgery done, the impact of the 80-hour workweek on resident experiences with urgent and emergent conditions has also been significant. The impact of this on the development of resident independence and autonomy has not been analyzed. This article will attempt to describe qualitatively the nature of the changes, the negative impacts on resident training, and some proposed measures to mitigate the impact. ENVIRONMENTAL AND TECHNOLOGICAL CHANGE IN DISEASE MANAGEMENT Four common disease categories, which involve intraabdominal pathology, have undergone major technological change in management during the last 20 years. Benign Peptic Ulcer Disease Benign gastric and duodenal ulcer disease has been a staple of general surgical management for decades, for treatment of the complications of bleeding, perforation, and intractability. Three advances in medical treatment have markedly altered the incidence of these complications, and the consequent need for surgical intervention: H2 receptor blockers, proton pump inhibitors, and treatment of Helicobacter pylori gastric infection. As a result of medical management with these 3 modalities, intractability of ulcer disease has virtually disappeared, and perforation and hemorrhage have been markedly reduced. The result is that surgery is infrequently necessary today for treatment of peptic ulcer complications and resident experience with gastric surgery is largely limited to malignancy and other less common conditions. Interestingly, the increase in laparoscopic bariatric surgery has provided the bulk of a typical resident experience in gastric surgery in recent years, but exposure to these procedures is highly variable, and residents are rarely the operating surgeon in these complex technical procedures.

The effect of robotic assistance on learning curves for basic laparoscopic skills

BACKGROUND We hypothesized that laparoscopic tasks performed with ZEUS robotic assistance would be done with greater precision and with a different learning curve than when performed in a standard laparoscopic trainer. METHODS Participants were divided into the surgically experienced (n = 11) and the surgically naive (n = 17). Two laparoscopic tasks (bead transfer and rope pass) were repeated for five repetitions. RESULTS For all drills and participants, completion time and error rate decreased across the five repetitions for each platform. Precision averaged 97% for both platforms over all drills. For both groups, completion time for tasks was shorter on the laparoscopic platform. ZEUS allowed for greater consistency in performance. CONCLUSIONS Compared with performance on a standard laparoscopic trainer, robotic assistance allows for increasing speed and consistency while maintaining precision over multiple repetitions. Understanding how robotics affects learning curves will allow for modifications in the training experience with this new technology.

Operative Experience of Surgery Residents: Trends and Challenges

OBJECTIVE To evaluate trends in operative experience and to determine the effect of establishing the Surgical Council on Resident Education (SCORE) operative classification system on changes in operative volume among graduating surgery residents. DESIGN The general surgery operative logs of graduating surgery residents from 2005 were retrospectively compared with residents who completed training in 2010 and 2011. Nonparametric statistical analyses were used (Mann-Whitney and median test) with significance set at p<0.01. PARTICIPANTS A total of 1022 residents completing residency in 2005 were compared with 1923 residents completing training in 2010-2011. RESULTS Total operations reported increased from a median of 1023 to 1238 (21%) between 2005 and 2010-2011 (p<0.001). Cases increased in most SCORE categories. The median numbers of total, basic, and complex laparoscopic operations increased by 49%, 37%, and 82%, respectively, over the 5-year interval (p<0.001). Open cavitary (thoracic + abdominal) operations decreased by 5%, whereas other major operations increased by 35% (both p<0.001). The frequency of discrete operations done at least 10 times during residency did not change. The median number of SCORE essential-common operations performed ranged from 1 to 107, whereas essential-uncommon operations ranged from 0 to 4. Twenty-three of 67 SCORE essential-common operations (34%) had a median of less than 5 and 4 had a median of 0. CONCLUSIONS The operative volume of graduating surgical residents has increased by 21% since 2005; however, the number of operations done 10 times or greater has not changed. Although open cavitary procedures continue to decline, there has been a large increase in endoscopy, complex laparoscopic, and other major operations. Some essential-common operations continue to be performed infrequently. These results suggest that education in the operating room must improve and alternate methods for teaching infrequently performed procedures are needed.

Obesity does not adversely affect the outcome of laparoscopic antireflux surgery (LARS)

Background: Because it has been suggested that obesity adversely affects the outcome of LARS, it is unclear how surgeons should counsel obese patients referred for antireflux surgery. Methods: A prospective database of patients undergoing LARS from 1992 to 2001 was used to compare obese and nonobese patients. Patients were surveyed preoperatively and annually thereafter. Questionnaires were completed regarding global symptoms and overall satisfaction. Results: Of the 505 patients, the body mass index (BMI) was <25 (normal) in 16%, 25–29 (overweight) in 42%, and >30 (obese) in 42%. Although the operative time was longer in the obese group than in the normal weight group (137 ± 55 min vs 115 ± 42 min, p = 0.003), the time to discharge and rate of complications did not differ. At a mean follow-up of 35 ± 25 months, there were no differences in symptoms, overall improvement, or patient satisfaction. Further, the rates of anatomic failure were similar among the obese, overweight, and normal weight groups. Conclusions: Although the operative time is longer in the obese, complication and anatomic failure rates are similar to those in the nonobese at long-term follow-up. Obese patients have equivalent symptom relief and are equally satisfied postoperatively. Therefore, obesity should not be a contraindication to LARS.

Long-term Outcomes of Performing a Postdoctoral Research Fellowship During General Surgery Residency

Objective:To determine whether dedicated research time during surgical residency leads to funding following postgraduate training. Summary Background Data:Unlike other medical specialties, a significant number of general surgery residents spend 1 to 3 years in dedicated laboratory research during their training. The impact this has on obtaining peer reviewed research funding after residency is unknown. Methods:Survey of all graduates of an academic general surgery resident program from 1990 to 2005 (n = 105). Results:Seventy-five (71%) of survey recipients responded, of which 66 performed protected research during residency. Fifty-one currently perform research (mean effort, 26%; range, 2%–75%). Twenty-three respondents who performed research during residency (35%) subsequently received independent faculty funding. Thirteen respondents (20%) obtained NIH grants following residency training. The number of papers authored during resident research was associated with obtaining subsequent faculty grant support (9.3 vs. 5.2, P = 0.02). Faculty funding was associated with obtaining independent research support during residency (42% vs. 17%, P = 0.04). NIH-funded respondents spent more combined years in research before and during residency (3.7 vs. 2.8, P = 0.02). Academic surgeons rated research fellowships more relevant to their current job than private practitioners (4.3 vs. 3.4 by Likert scale, P < 0.05). Both groups considered research a worthwhile use of their time during residency (4.5 vs. 4.1, P = not significant). Conclusions:A large number of surgical trainees who perform a research fellowship in the middle of residency subsequently become funded investigators in this single-center survey. The likelihood of obtaining funding after residency is related to productivity and obtaining grant support during residency as well as cumulative years of research prior to obtaining a faculty position.

Prevalence and Cost of Full-Time Research Fellowships During General Surgery Residency - A National Survey

Objective:To quantify the prevalence, outcomes, and cost of surgical resident research. Summary Background Data:General surgery is unique among graduate medical education programs because a large percentage of residents interrupt their clinical training to spend 1 to 3 years performing full-time research. No comprehensive data exists on the scope of this practice. Methods:Survey sent to all 239 program directors of general surgery residencies participating in the National Resident Matching Program. Results:Response rate was 200 of 239 (84%). A total of 381 of 1052 trainees (36%) interrupt residency to pursue full-time research. The mean research fellowship length is 1.7 years, with 72% of trainees performing basic science research. A significant association was found between fellowship length and postresidency activity, with a 14.7% increase in clinical fellowship training and a 15.2% decrease in private practice positions for each year of full-time research (P < 0.0001). Program directors at 31% of programs reported increased clinical duties for research fellows as a result of Accreditation Council for Graduate Medical Education work hour regulations for clinical residents, whereas a further 10% of programs are currently considering such changes. It costs

Teaching operating room conflict management to surgeons: clarifying the optimal approach

41.5 million to pay the 634 trainees who perform research fellowships each year, the majority of which is paid for by departmental funds (40%) and institutional training grants (24%). Conclusions:Interrupting residency to perform a research fellowship is a common and costly practice among general surgery residents. Although performing a research fellowship is associated with clinical fellowship training after residency, it is unclear to what extent this practice leads to the development of surgical investigators after postgraduate training.

Laparoscopic incisional hernia repair in a porcine model: What do transfixion sutures add?

Medical Education 2011:45: 939–945

Transition to surgical residency: a multi-institutional study of perceived intern preparedness and the effect of a formal residency preparatory course in the fourth year of medical school.

Background: The aim of this study was to evaluate the need for transfixion sutures during laparoscopic ventral hernia repair with mesh. Methods: Incisional hernias were created in 14 Yucatan mini-pigs. Animals were randomized to undergo laparoscopic hernia repair either with spiral tacks alone (Tacks) or with tacks and 4 Prolene transfixion sutures (Sutured) using Composix E/X mesh (Davol Inc.). At 4 weeks, exploratory laparoscopy was performed to assess the repair and score adhesions. The abdominal wall was harvested for tensile strength analysis and histologic evaluation. Continuous variables were compared using a two-tailed nonpaired t-test. Results are presented as mean ± standard deviation. Results: The mean hernia size was 8.5 ± 0.5 cm by 5.5 ± 0.7 cm, with no difference between groups. The operative time was significantly longer (p = 0.006) for the Sutured group (62.1 ± 16.8 min) than for the Tacks group (32.3 ± 7.0 min). The number of tacks per repair was equivalent between groups. At necropsy, the mesh in all cases was well incorporated, reperitonealized, and without evidence of migration. No hernias recurred. However, the Sutured group had a significantly (p ≤ 0.05) higher adhesion score (5.4 ± 3.3) than the Tacks group (2.0 ± 2.7). The tensile strength of the repair zone was no different between groups (Sutured 4.8 ± 1.5 N/cm, Tacks 3.8 ± 1.4 N/cm). On histologic examination, the ratio of inflammatory cells to fibroblasts was similar between groups (Sutured 0.2 ± 0.6, Tacks 0.2 ± 0.3). Only 82% of tacks in each group penetrated the fascia, and the depth of tack penetration was similar between groups (Sutured 3.7 ± 0.3 mm, Tacks 3.9 ± 0.4 mm). Conclusions: In a porcine model, the use of transfixion sutures was associated with longer operative times and more adhesions, without improvement in tensile strength or mesh incorporation. A human clinical trial is needed to determine the optimal method of securing abdominal wall mesh.