Shahzad M. Ali

Impact of resident participation on laparoscopic inguinal hernia repairs: are residents slowing us down?

OBJECTIVE The time it takes to complete an operation is important. Operating room (OR) time is costly and directly associated with infectious complications and length of stay. Intuitively, procedures take longer when a surgical resident is operating. How much extra time should we take to train residents? We examined the relationship between laparoscopic inguinal hernia repair (IHR) procedure duration and resident participation and its impact on the development of complications and hospital stay. METHODS Data from patients undergoing laparoscopic IHR in participating institutions of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2007 to 2009 were retrospectively reviewed. Patients with current procedural terminology (CPT) codes 49650 and 49651 (laparoscopic initial and recurrent IHR) comprised our patient cohort. Participation of staff surgeon and resident postgraduate year level (PGY) were used as the main predictors for operative outcomes. RESULTS A total of 6223 patients underwent laparoscopic IHR as their main procedure with no additional or concurrent procedures; 92% were men, 21% of the repairs were bilateral. In total, there were 98 patients with at least 1 complication (1.6%). Resident involvement was present in 3565 cases (57%) broken down by PGY1: 12%, PGY2: 12%, PGY3: 21%, PGY4: 19%, PGY5 or above: 36%. Median operative time was 45 minutes for staff surgeons alone and 64 minutes when there was a resident present (p < 0.001). PGY level predicted operative duration: higher PGY levels correlated with greater operative times (PGY1 median time 58 min vs PGY ≥ 5 = 67 min, p < 0.001). Resident participation was not a significant predictor for the development of complications (p = 0.30). CONCLUSIONS Laparoscopic IHR is performed faster by staff surgeons without residents. There was no difference in the complication rate when residents were involved. Teaching and mentoring residents in the OR for laparoscopic IHR is safe and laudable.

Incidence of inguinal hernia repairs in Olmsted County, MN: a population-based study.

Objective: To determine age- and sex-specific incidence rates of inguinal hernia repairs (IHR) in a well-defined US population and examine trends over time. Background Data: IHR represent a substantial burden to the US healthcare system. An up-to-date appraisal will identify future healthcare needs. Methods: A retrospective review of all IHR performed on adult residents of Olmsted County, MN, from 1989 to 2008 was performed. Cases were ascertained through the Rochester Epidemiology Project, a record linkage system with more than 97% population coverage. Incidence rates were calculated by using incident cases as the numerator and population counts from the census as the denominator. Trends over time were evaluated using Poisson regression. Results: During the study period, a total of 4026 IHR were performed on 3599 unique adults. Incidence rates per 100,000 person-years were greater for men: 368 versus 44 for women, and increased with age: from 194 to 648 in men, and from 28 to 108 in women between 30 and 70 years of age. Initial, unilateral IHR comprised 74% of all IHR types. The lifelong cumulative incidence of an initial, unilateral or a bilateral IHR in adulthood was 42.5% in men and 5.8% in women. Over time (from 1989 to 2008), the incidence of initial, unilateral IHR in men decreased from 474 to 373 (relative reduction, RR = 21%). Bilateral IHR increased from 42 to 71 (relative increase = 70%), contralateral metachronous IHR decreased from 29 to 11 (RR = 62%), and recurrent IHR decreased from 66 to 26 (RR = 61%); for all changes P < 0.001. Conclusions: IHR are common, their incidence varies greatly by age and sex and has decreased substantially over time in Olmsted County, MN.

Trends in the utilization of inguinal hernia repair techniques: a population-based study

BACKGROUND The use of inguinal hernia repair techniques in the community setting is poorly understood. METHODS A retrospective review of all inguinal hernia repairs performed on adult residents of Olmsted County, MN, from 1989 to 2008 was performed through the Rochester Epidemiology Project. RESULTS A total of 4,433 inguinal hernia repairs among 3,489 individuals were reviewed. Non-mesh-based repairs predominated in the late 1980s (94% in 1989), declined throughout the 1990s (40% in 1996), and are rarely used nowadays (4% in 2008). Open mesh-based repairs comprised 21% in 1990, peaked in 2001 with 72%, and declined to 55% in 2008. The adoption of laparoscopic repairs began in 1992 (6%) and has increased steadily to 41% in 2008 (P < .001). CONCLUSIONS Although non-mesh-based repairs, once the predominant method, have been supplanted by open mesh-based techniques, nowadays the use of laparoscopic inguinal hernia repair techniques has increased substantially to nearly equal that of open mesh-based techniques.

Model to predict survival after surgical resection of intrahepatic cholangiocarcinoma: the Mayo Clinic experience

BACKGROUND The 7th edition of the American Joint Committee on Cancer (AJCC) staging system has recently been validated and shown to predict survival in patients with intrahepatic cholangiocarcinoma (ICC). The present study attempted to investigate the validity of these findings. METHODS A single-centre, retrospective cohort study was conducted. Histopathological restaging of disease subsequent to primary surgical resection was carried out in all consecutive ICC patients. Overall survival was compared using Kaplan-Meier estimates and log-rank tests. RESULTS A total of 150 patients underwent surgery, 126 (84%) of whom met the present studys inclusion criteria. Of these 126 patients, 68 (54%) were female. The median length of follow-up was 4.5 years. The median patient age was 58 years (range: 24-79 years). Median body mass index was 27 kg/m(2) (range: 17-46 kg/m(2) ). Staging according to the AJCC 7th edition categorized 33 (26%) patients with stage I disease, 27 (21%) with stage II disease, five (4%) with stage III disease, and 61 (48%) with stage IVa disease. The AJCC 7th edition failed to accurately stratify survival in the current cohort; analysis revealed significantly worse survival in those with microvascular invasion, tumour size of >5 cm, grade 4 disease, multiple tumours and positive lymph nodes (P < 0.001). A negative resection margin was associated with improved survival (P < 0.001). CONCLUSIONS The AJCC 7th edition did not accurately predict survival in patients with ICC. A multivariable model including tumour size and differentiation in addition to the criteria used in the AJCC 7th edition may offer a more accurate method of predicting survival in patients with ICC.

Preclinical electrogastrography in experimental pigs

Preclinical electrogastrography in experimental pigs Surface electrogastrography (EGG) is a non-invasive means of recording gastric myoelectric activity or slow waves from cutaneous leads placed over the stomach. This paper provides a comprehensive review of preclinical EGG. Our group recently set up and worked out the methods for EGG in experimental pigs. We gained our initial experience in the use of EGG in assessment of porcine gastric myoelectric activity after volume challenge and after intragastric administration of itopride and erythromycin. The mean dominant frequency in pigs is comparable with that found in humans. EGG in experimental pigs is feasible. Experimental EGG is an important basis for further preclinical projects in pharmacology and toxicology.

Handing Over Patient Care: Is it Just the Old Broken Telephone Game?

BACKGROUND Handing over patient care remains a poorly understood process and remains a leading cause of medical error. We sought to examine how hand off delivery methods affect hand off quality and whether improvement would occur over time without formal training. DESIGN Three simulated-patient hand offs were developed; each with a distinct delivery method: in-person (IP), video-based (VB), and screen-based (SB). Participants were evaluated up to 4 times, each 6 months apart. During evaluations, residents received the 3 hand offs, answered a sleep and preference questionnaire, and proceeded to hand off the same 3 patients. Sessions were video-reviewed and hand offs scored for quality measures: word accuracy, errors of omission or commission, and appropriateness of clinical judgment. Quality measures among delivery methods and changes over time were compared. RESULTS Sixty-eight General Surgery residents (postgraduate year [PGY] 1-2) participated in at least 2 testing sessions, with 13 participating in 4. The IP method was superior to VB and SB for most hand off quality measures (each p < 0.001). With repeated testing, hand off quality measures improved (p < 0.001). However, patient hand offs continued to remain non-optimal, with appropriate judgment present in only 47%-77% of the hand offs. Sleep hours (mean 5 ± 2) were not found to be associated with hand off quality measures (p > 0.05). Most trainees preferred the IP method (73% vs 5% VB, 15% SB, 7% other; p < 0.001). CONCLUSIONS There is a need to provide formal training in hand off quality early in residency training. General surgery trainees clearly prefer and performed better, though not perfect, hand offs with the in-person method.

Annual Surgeon Volume and Patient Outcomes Following Laparoscopic Totally Extraperitoneal Inguinal Hernia Repairs

PURPOSE Data on laparoscopic totally extraperitoneal inguinal hernia repairs (TEP-IHRs) suggest that approximately 250 operations are needed to gain mastery, but the annual volume required to maintain high-quality outcomes is unknown. MATERIALS AND METHODS A retrospective review was performed of every patient undergoing a TEP-IHR at the Mayo Clinic (Rochester, MN) from 1995 to 2011. Analysis focused on the annual volume of 21 staff surgeons and their specific patient outcomes broken up into three groups: Group 1 (G1) (n = 1 surgeon) performed >30 repairs per year; Group 2 (G2) (n = 3 surgeons), 15-30 repairs; and Group 3 (G3) (n = 17), <15 repairs. RESULTS In total, 1601 patients underwent 2410 TEP-IHRs, with no significant patient demographic differences among groups. Greater annual surgeon volume (G1 > G2 > G3) was associated with improved outcomes as shown by the respective rates for intra- (1%, 2.6%, and 5.6%) and postoperative (13%, 27%, and 36%) complications, need for overnight stay (17%, 23%, and 29%), and hernia recurrence (1%, 4%, and 4.3%) (all P < .05). Surgeons with greater annual operative volumes were more likely to operate on patients with bilateral and recurrent hernias. Surgeons performing at least 15 repairs per year (G1 and G2) showed improvements in quality metrics over time. CONCLUSIONS Annual operative volumes of >30 repairs per year are associated with the highest quality outcomes for TEP-IHR. Operative volumes of at least 15 repairs per year are associated with improvements in quality metrics over time. Mentorship and operative assistance of low-volume TEP-IHR surgeons may be useful in improving patient outcomes.

Optimizing training cost-effectiveness of simulation-based laparoscopic inguinal hernia repairs

BACKGROUND Motor learning theory suggests that highly complex tasks are probably best trained under conditions of part task (PT), as opposed to whole-task (WT) training. Within PT, random practice of tasks has been shown to lead to improved skill retention and transfer. METHODS General surgery residents were equally randomized to PT vs WT, mastery learning type, and simulation-based training of laparoscopic inguinal hernia repair. Training time and resources used to reach mastery (skill acquisition), performance at 1-month testing (skill retention), and intraoperative time and performance scores (skill transfer) were compared. RESULTS Forty-four general surgery trainees were randomized. All residents achieved mastery benchmarks. Trainees in the PT group achieved mastery on average 17 minutes faster (60.2 ± 23.8 vs 77.1 ± 24.8 minutes, P = .02, saving 6.2 instructor hours), used fewer material resources (curricular cost savings of

Safety of an Enhanced Recovery Pathway for Patients Undergoing Open Hepatic Resection

2,380 or

Lessons learned from an unusual case of inflammatory breast cancer.

121 per learner), and were more likely to retain mastery level performance at 1-month retention testing (59% vs 22.7% P = .03). No differences in intraoperative performance were encountered. CONCLUSIONS For laparoscopic inguinal hernia repair, random PT simulation-based training seems to be more cost-effective, compared with WT training.