Scott Ellner

Thirty-Day Outcomes Support Implementation of a Surgical Safety Checklist

BACKGROUND Thirty-day postoperative complications from unintended harm adversely affect patients and their families and increase institutional health care costs. A surgical checklist is an inexpensive tool that will facilitate effective communication and teamwork. Surgical team training has demonstrated the opportunity for stakeholders to professionally engage one another through leveling of the authority gradient to prevent patient harm. The American College of Surgeons National Surgical Quality Improvement Program database is an outcomes reporting tool capable of validating the use of surgical checklists. STUDY DESIGN Three 60-minute team training sessions were conducted and participants were oriented to the use of a comprehensive surgical checklist. The surgical team used the checklist for high-risk procedures selected from those analyzed for the American College of Surgeons National Surgical Quality Improvement Program. Trained observers assessed the checklist completion and collected data about perioperative communication and safety-compromising events. RESULTS Data from the American College of Surgeons National Surgical Quality Improvement Program were compared for 2,079 historical control cases, 246 cases without checklist use, and 73 cases with checklist use. Overall completion of the checklist sections was 97.26%. Comparison of 30-day morbidity demonstrated a statistically significant (p = 0.000) reduction in overall adverse event rates from 23.60% for historical control cases and 15.90% in cases with only team training, to 8.20% in cases with checklist use. CONCLUSIONS Use of a comprehensive surgical safety checklist and implementation of a structured team training curriculum produced a statistically significant decrease in 30-day morbidity. Adoption of a comprehensive checklist is feasible with team training intervention and can produce measurable improvements in patient outcomes.

Surgical Value of Elective Minimally Invasive Gallbladder Removal: A Cost Analysis of Traditional 4-Port vs Single-Incision and Robotically Assisted Cholecystectomy

BACKGROUND As the cost of health care is subjected to increasingly greater scrutiny, the assessment of new technologies must include the surgical value (SV) of the procedure. Surgical value is defined as outcome divided by cost. STUDY DESIGN The cost and outcome of 50 consecutive traditional (4-port) laparoscopic cholecystectomies (TLC) were compared with 50 consecutive, nontraditional laparoscopic cholecystectomies (NTLC), between October 2012 and February 2014. The NTLC included SILS (n = 11), and robotically assisted single-incision cholecystectomies (ROBOSILS; n = 39). Our primary outcomes included minimally invasive gallbladder removal and same-day discharge. Thirty-day emergency department visits or readmissions were evaluated as a secondary outcome. The direct variable surgeon costs (DVSC) were distilled from our hospital cost accounting system and calculated on a per-case, per item basis. RESULTS The average DVSC for TLC was

Commentary: Robotic vs. standard laparoscopic technique - what is better?

929 and was significantly lower than NTLC at

Commentary: How Long Do We Need to Follow-Up Our Hernia Patients to Find the Real Recurrence Rate?

2,344 (p < 0.05), SILS at

Are You Capable of Providing High Quality Care

1,407 (p < 0.05), and ROBOSILS at

Healthcare-Associated Infections in Surgical Practice

2,608 (p < 0.05). All patients achieved the same primary outcomes: minimally invasive gallbladder removal and same day discharge. There were no differences observed in secondary outcomes in 30-day emergency department visits (TLC [2%] vs NTLC [6%], p = 0.61) or readmissions (TLC [4%] vs NTLC [2%], p > 0.05), respectively. The relative SV was significantly higher for TLC (1) compared with NTLC (0.34) (p < 0.05), and SILS (0.66) and ROBOSILS (0.36) (p < 0.05). CONCLUSIONS Nontraditional, minimally invasive gallbladder removal (SILS and ROBOSILS) offers significantly less surgical value for elective, outpatient gallbladder removal.

Use of a Modified American College of Surgeons Trauma Quality Improvement Program to Enhance 30-Day Post-Trauma Readmission Detection

We read with great interest the recently published article by Ferdinand Kockerling in Frontiers in Surgery (1). The author has provided expert insight into the role of robotic surgery in common abdominal, bariatric, colorectal, and oncologic procedures. The robotic approach allows superiority over the traditional laparoscopic abdominal surgery in terms of a three-dimensional high definition view, seven degrees of freedom of motion, intuitive movements, tremor filtering, and other advantages due to its inherent design (2). Experienced surgeons claim comparable or better outcomes for patients undergoing robotic surgery. We had recently compared the surgical value, which is defined as the outcome of the procedure divided by the cost to achieve that outcome, of traditional laparoscopic cholecystectomy to the robotic approach. Our outcomes were comparable to national standards in terms of complications, length of stay and readmissions but we became granular with the procedure cost wherein we accounted for supplies, equipment, per use or annual contract costs, and for the operating room (OR) time. Our calculations clearly showed a lower surgical value for the robotic approach. Similarly, concerns for a higher cost have been described for pancreatic surgery (3), colorectal surgery (4), and bariatric surgery (5). Some studies claim a lesser cumulative cost due to a reduction in the hospital length of stay, but at the same time the question arises that how is this reduction in length of stay being achieved if both the laparoscopic and robotic procedures are near similar. Waters et al. (3) reported a shorter average length of stay in their robotic distal pancreatic cohort but that was because of outliers in the laparoscopic group which stayed in excess of 3 weeks. Similarly, the literature is abundant with studies vouching for comparable outcomes but they are plagued with a selection bias for patients with favorable anatomy or a lesser acuity of the disease. This just highlights the dire need to shift from observational data and move toward prospective randomized trials. Robotic surgery is going through a phase of exponential growth (6). Salisbury et al. (7) commented that structured cross pollination between surgeons and engineers will bridge current deficiencies in robotics. Critical access hospitals may continue to stall on investing due to technology costs, but if this evolution in robotics leads to improved outcomes that argument will be very hard to hold onto. Future improvements expected in robotics aim to miniaturize the console and reduce OR set-up times. These improvements will also include tactile and force sensors to address the lack of haptic feedback. Other advancements are likely to include motion and force scaling for greater precision, and the ability to establish virtual operative boundaries to avoid damaging vital structures. With an industry geared and motivated to redefining surgical norms, my biggest concern is that general surgeons will fall behind the curve and be forced to play catch up. It is critical that adequate education and training keep pace with technology, so the next generation is prepared to recognize and take advantage of the opportunities robotics may provide. The robotics era is currently catering to the demand for increased patient autonomy but the question remains whether there is sufficient value for critical access hospitals to invest resources in a technology still in its infancy. Training and credentialing remains a big concern and so is the steep learning curve which can potentially introduce a risk for serious injury to patients. This may be part of the reason why penetrance of the robotic approach in visceral surgery has been slow and there has been negligible integration in residency curriculums to introduce the skill early in the surgical career of trainees. Having done this meticulous review, we would like to know the authors view on the future of robotic surgery. We do not think there is evidence in these observational studies that robotic surgery provides enough surgical value. That, however, may change with new innovations in the field. Is it possible that traditional laparoscopic surgeons are resisting the tide of change the same way general surgeons were when laparoscopy was first introduced?

The Use of an Indwelling Catheter Protocol to Reduce Rates of Postoperative Urinary Tract Infections.

It was a pleasure to go through the manuscript by Ferdinand Kockerling focusing on hernia recurrence in Frontiers in Surgery (1). We would like to applaud the authors on two fronts. We had very peripheral awareness of the Herniamed registry, but having read this paper, we believe that the registry is a brilliant initiative by the German surgical society. Such data sharing will most definitely help to evolve and standardize practices in hernia surgery across the board. Second, the results and recommendations of this study are novel in nature. The recurrence rates followed over such a long interval have important implications for managing follow-up care for hernia patients. Recurrence and wound infection rates, postoperative neuralgia, hospital length of stay, and return to normal activity are important metrics that define the success of any incisional or inguinal hernia repair. Outcomes in hernia repair can not only be attributed to its inherent anatomy (size, location, severity) but also strongly influenced by the type of repair. There is sufficient literature that favors the superiority of mesh repair over suture repair (2–4). Similarly, Bassini repairs have higher recurrence rates when compared to the non-Bassini repairs (4). No significant difference in hernia recurrence has been found between open and laparoscopic techniques that utilized mesh (5), but differences still exist in return to normal activity and hospital length of stay. Another obstacle to the success of any herniorrhaphy is the experience of the surgeon. Aquina et al. found differences in surgeon experience contributing to the hernia recurrence rates, i.e., surgeons performing <25 cases annually were associated with a higher rate of recurrence [hazard ratio 1.23, 95% CI (1.11–1.36)] (6). Cumulative recurrence rates as presented by the author for inguinal and incisional hernias (1) are definitely useful, but we fear it might be an over-simplification. In light of the potential confounders, we would like to request the authors to present a subset analysis of recurrences over time compared between repairs with and without mesh, and also between herniorrhaphy done by high volume and low volume surgeons from their study cohort. Our hypothesis is that a suture repair or any hernia repair in the hands of an inexperienced surgeon has a greater potential of being technically inadequate, and might require a close interval follow-up. On the contrary, a superior mesh repair done by an experienced surgeon could likely require a longer interval follow-up. In a subset analysis, Burger et al. (7) found that 67% of their incisional hernias recurred within 10 years in their suture repair group compared to 17% in the mesh group. Our concern is that in addition to the type of hernia, the type of repair should significantly influence recurrence patterns as well. Nicolas Jean Marjolin stated back in 1828 that surgery has reached such a level of improvement that nothing further can be expected. That judgment may be far from the truth, but unfortunately the paragon of surgical precision still eludes us in this day and age. Inguinal herniorrhaphy is one of the most commonly performed general surgical procedures but it can still be technically challenging. Continuous training is essential to achieve proficiency. Part of the reason why hernia recurrences continue to plague us is because we continue to employ redundant techniques. As health care delivery systems become increasingly patient centered, patient outcomes, which in turn reflect on the quality of care delivered, will drive health care economics. This provides strong incentive to move forward with best care practices supported by evidence-based medicine guidelines in hernia surgery. The findings of the Herniamed registry are definitely a step in the right direction. In the future, such registries can potentially help us generate predictive models for complications, which include recurrence, and tackle them in a timely and more effective manner, if not completely avoid them altogether.

Incidence and Risk Factors for Postoperative Urinary Retention: A Retrospective, Observational Study with a Literature Review of Preventive Strategies.

Quality improvement (QI) initiatives have intensified in the healthcare workplace with only a nascent understanding of the definition of quality in healthcare. As physicians, we adhere to the Hippocratic aphorism of “do no harm” and therefore, often delude ourselves into believing that we are functioning at the top of our clinical capacity and knowledge for the benefit of our patients. It is undeniable that nearly all physicians want to do what is best for their patients. However, maximizing the potential for improved outcomes can prove challenging.

Traditional Four-Port vs Single-Incision and Robotically Assisted Cholecystectomy: In reply to Bloomstone and colleagues

Healthcare-associated infections (HAIs) pose a unique challenge that requires engagement from all tiers of healthcare organizations. The solution relies on implementing infection prevention policies that acknowledge the interaction between biologic and structural factors that contribute to HAIs. Additional dynamics require understanding and reforming organizational culture, which can be harder than expected. Institutional capacity to endorse patient safety is paramount to sustainable change and is closely tethered to the degree of attainable success.