William W. Hope

Initial Laparoscopic Basic Skills Training Shortens the Learning Curve of Laparoscopic Suturing and Is Cost-Effective

BACKGROUNDnLaparoscopic suturing is an advanced skill that is difficult to acquire. Simulator-based skills curricula have been developed that have been shown to transfer to the operating room. Currently available skills curricula need to be optimized. We hypothesized that mastering basic laparoscopic skills first would shorten the learning curve of a more complex laparoscopic task and reduce resource requirements for the Fundamentals of Laparoscopic Surgery suturing curriculum.nnnSTUDY DESIGNnMedical students (n = 20) with no previous simulator experience were enrolled in an IRB-approved protocol, pretested on the Fundamentals of Laparoscopic Surgery suturing model, and randomized into 2 groups. Group I (n = 10) trained (unsupervised) until proficiency levels were achieved on 5 basic tasks; Group II (n = 10) received no basic training. Both groups then trained (supervised) on the Fundamentals of Laparoscopic Surgery suturing model until previously reported proficiency levels were achieved. Two weeks later, they were retested to evaluate their retention scores, training parameters, instruction requirements, and cost between groups using t-test.nnnRESULTSnBaseline characteristics and performance were similar for both groups, and 9 of 10 subjects in each group achieved the proficiency levels. The initial performance on the simulator was better for Group I after basic skills training, and their suturing learning curve was shorter compared with Group II. In addition, Group I required less active instruction. Overall time required to finish the curriculum was similar for both groups; but the Group I training strategy cost less, with a savings of

The eighty-hour workweek: surgical attendings' perspectives.

148 per trainee.nnnCONCLUSIONSnTeaching novices basic laparoscopic skills before a more complex laparoscopic task produces substantial cost savings. Additional studies are needed to assess the impact of such integrated curricula on ultimate educational benefit.

Does prophylactic mesh placement in elective, midline laparotomy reduce the incidence of incisional hernia? A systematic review and meta-analysis

OBJECTIVEnThe year 2008 was a sentinel year in resident education; this was the first graduating general surgery class trained entirely under the 80-hour workweek. The purpose of this study was to evaluate attending surgeon perceptions of surgical resident attitudes and performance before and after duty-hour restrictions.nnnDESIGNnAn electronic survey was sent to all surgical teaching institutions in North Carolina. Both surgeon and hospital characteristics were documented. The survey consisted of questions designed to assess residents attitudes/performance before and after the implementation of the work-hour restriction.nnnRESULTSnIn all, 77 surveys were returned (33% response rate). The survey demonstrated that 92% of educators who responded to the survey recognized a difference between the restricted residents (RRs) and the nonrestricted residents (NRRs), and most respondents (67%) attributed this to both the work-hour restrictions and the work ethic of current residents. Most attending surgeons reported no difference between the RRs and the NRRs in most categories; however, they identified a negative change in the areas of work ethic, technical skills development, decision-making/critical-thinking skills, and patient ownership among the RR group. Most surgeons expressed less trust (55%) with patient care and less confidence (68%) in residents ability to operate independently in the RR group. Eighty-nine percent indicated that additional decreases in work hours would continue to hamper the mission of timely and comprehensive resident education.nnnCONCLUSIONSnThe perception of surgical educators was that RRs are clearly different from the NRRs and that the primary difference is in work ethic and duty-hour restrictions. Although similar in most attributes, RRs are perceived as having a lower baseline work ethic and a less developed technical skill set, decision-making ability, and sense of patient ownership. Subsequent study is needed to evaluate these concerns.

Laparoscopic-assisted small bowel resection for treatment of adult small bowel intussusception: a case report

Background. Operative intervention to correct incisional hernia affects 150,000 patients annually, with 1 in 3 repairs recurring within 9 years. The aim of this study was to compare the incidence of incisional hernia and postoperative complications in elective midline laparotomy patients after the use of prophylactic mesh placement and primary suture closure. Methods. A systematic review was performed to identify studies comparing prophylactic mesh placement to primary suture closure in elective, midline laparotomy at index abdominal aponeurosis closure. The primary outcome was incisional hernia. Secondary outcomes included postoperative complications. Results. Fourteen studies were included (2,114 patients), with 1,152 receiving prophylactic mesh placement. Prophylactic mesh placement decreased the risk of incisional hernia overall when compared to primary suture closure (relative risk = 0.15; P < .00001) and in trials using only polypropylene mesh versus 4:1 primary suture closure (relative risk = 0.15; P = .003). Prophylactic mesh placement reduced the risk of incisional hernia regardless of mesh location or composition: onlay (relative risk = 0.07; P < .0001), retrorectus (relative risk = 0.04; P = .002), and preperitoneal (relative risk = 0.18; P = .02). Prophylactic mesh placement increased risk of seroma overall (relative risk = 1.95; P < .0001), onlay (relative risk = 2.43; P = .01) and preperitoneal (relative risk = 1.47; P = .01) but not retrorectus plane (relative risk = 1.55; P = .26). Polypropylene mesh increased seroma risk only in the onlay position (relative risk = 2.77; P = .04). Prophylactic mesh placement patients are at increased risk for chronic wound pain compared to primary suture closure (relative risk = 1.70; P = .03). Conclusion. Prophylactic mesh placement is associated with an 85% postoperative incisional hernia risk reduction when compared to primary suture closure in at‐risk patients undergoing elective, midline laparotomy closure. This technique appears to be safe with comparable complication profiles, barring an increased risk of seroma, especially with the onlay technique, and the possibility for an increased risk of chronic pain. Despite this verification, evidence from large domestic trials that sufficiently addresses major knowledge gaps is simply lacking.

Proper catheter selection for needle thoracostomy: A height and weight-based criteria

BackgroundIntussuception is a rare cause of intestinal obstruction in adults. Diagnosis is often difficult due to the variable and sometimes episodic nature of symptoms. Surgery is the recommended treatment option in adults if the diagnosis is proven.Case presentationWe present a case of a 33 year old Caucasian female admitted with a small bowel obstruction and no history of previous abdominal surgery. Patient did not improve with medical management consisting of bowel rest and nasogastric tube decompression. Surgery was consulted and patient was taken to the operating room for a laparoscopic-assisted small bowel resection for a small bowel intussusception caused by a submucosal fibroma.ConclusionOur case highlights the feasibility and potential benefits of laparoscopy in assisting the diagnosis and treatment of small bowel obstructions.

Use of Stent Grafts in Lower Extremity Trauma

BACKGROUNDnObesity increases the incidence of mortality in trauma patients. Current Advanced Trauma Life Support guidelines recommend using a 5-cm catheter at the second intercostal (ICS) space in the mid-clavicular line to treat tension pneumothoraces. Our study purpose was to determine whether body mass index (BMI) predicted the catheter length needed for needle thoracostomy.nnnMETHODSnWe retrospectively reviewed trauma patients undergoing chest computed tomography scans January 2004 through September 2006. A BMI was calculated for each patient, and the chest wall thickness (CWT) at the second ICS in the mid-clavicular line was measured bilaterally. Patients were grouped by BMI as underweight (≤ 18.5 kg/m2), normal weight (18.6-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)), or obese (≥ 30 kg/m(2)).nnnRESULTSnThree hundred twenty-six patients were included in the study; 70% were male. Ninety-four percent of patients experienced blunt trauma. Sixty-three percent of patients were involved in a motor vehicle collision. The average BMI was 29 [SD 7.8]. The average CWT was 6.2 [SD 1.9]cm on the right and 6.3 [SD 1.9]cm on the left. As BMI increased, a statistically significant (p<0.0001) CWT increase was observed in all BMI groups. There were no significant differences in ISS, ventilator days, ICU length of stay, or overall length of stay among the groups.nnnCONCLUSIONnAs BMI increases, there is a direct correlation to increasing CWT. This information could be used to quickly select an appropriate needle length for needle thoracostomy. The average patient in our study would require a catheter length of 6-6.5 cm to successfully decompress a tension pneumothorax. There are not enough regionally available data to define the needle lengths needed for needle thoracostomy. Further study is required to assess the feasibility and safety of using varying catheter lengths.

Non-operative Management in Penetrating Abdominal Trauma: IS it Feasible at a Level II Trauma Center?

BACKGROUNDnPermanent endovascular stenting is gradually becoming recognized as a safe and efficacious method for treating a variety of arterial diseases. The literature on its application in trauma care is sparse, although indications for usage continue to evolve.nnnMETHODSnWe retrospectively reviewed all penetrating extremity trauma treated with endovascular therapy at our medical center between 2005 and 2008.nnnRESULTSnWe present three patients with three different arterial lesions in the superficial femoral artery (SFA) which were caused by penetrating injury. The arterial lesions include a mid-thigh SFA pseudoaneurysm, an intimal disruption of the distal SFA, and an arteriovenous fistula involving the SFA and superficial femoral vein. All were treated with expanded polytetrafluoroethylene-covered stents and showed excellent short-term results. A percutaneous approach to this problem may reduce blood loss, decrease length of stay, involve fewer iatrogenic nerve injuries, and facilitate shorter recovery time, as compared with open approaches.nnnCONCLUSIONSnEndovascular-covered stent placement for traumatic arterial extremity injury was used with excellent results and no morbidity in this small series of patients. Endovascular solutions for arterial extremity injuries warrant further investigation for short- and long-term results.

Micropapillary thyroid carcinoma and concomitant ectopic thyroid tissue in the adrenal gland: metastasis or metaplasia?

BACKGROUNDnThe recent mandate for surgical exploration for all penetrating abdominal trauma has been questioned. High-volume centers report good outcomes for non-operative treatment in penetrating trauma for hemodynamically stable patients without peritonitis and with tangential wounds. The applicability of this strategy in smaller hospitals is unknown.nnnSTUDY OBJECTIVESnThe purpose of this study was to evaluate non-operative management of penetrating abdominal trauma at a Level II trauma center.nnnMETHODSnWe retrospectively reviewed all patients with penetrating abdominal trauma from 2006 through 2008. Demographic information, treatments, and outcomes were analyzed using descriptive statistics.nnnRESULTSnOur sample consisted of 86 patients with penetrating abdominal trauma; 12 (14%) had documented peritoneal violation and were managed non-operatively. The average age was 30 years (range 21-39 years), with 50% African American, 33% Caucasian, and 17% Hispanic. Male patients accounted for 92%, and the average Injury Severity Score was 5.2 (range 1-13). Overall non-operative treatment failed in 3 patients (25%); one required drainage of a retrogastric abscess on hospital day 4, and another underwent gastric and diaphragm repair on hospital day 1. The third treatment failure did not require an operation but developed a biloma requiring percutaneous drainage. There were no other complications related to non-operative therapy andxa0no mortalities. The average length of stay was 3.9 days;xa083% of patients were discharged home.nnnCONCLUSIONSnIn hemodynamically stable patients without peritonitis andxa0documented isolated injuries to solid organs, non-operative management of penetrating abdominal trauma seems safe; however, it can delay diagnosis of hollow viscus injuries. Until further data emerge, extreme caution should be used in employing non-operative management for penetrating abdominal injuries at small trauma centers.

Resident case coverage in the era of the 80-hour workweek.

BACKGROUNDnEctopic thyroid tissue is a rare finding but has been reported in many thoracic and abdominal locations. It is usually an incidental pathologic finding after an unrelated surgical intervention. When thyroid tissue is found outside the thyroid bed, it is important to rule out thyroid cancer metastasis.nnnPATIENT FINDINGSnWe present a case of a 61-year-old African American woman who was incidentally found to have concomitant ectopic thyroid tissue in the adrenal gland and a papillary thyroid microcarcinoma (PTMC) in the right lobe of the thyroid.nnnSUMMARYnThe concurrent finding of ectopic thyroid tissue and PTMC posed the diagnostic dilemma of whether the extrathyroidal tissue was metastasis or metaplasia, with very different treatment implications. Although many of these incidental micropapillary cancers are indolent, some patients do experience local or distant metastasis. Therefore, it is important to delineate which of these microtumors are likely to metastasize. Some tumor markers and gene mutations have been proposed to help differentiate the more benign tumors from the more aggressive tumors, but there is currently no standard method for determination of metastatic potential.nnnCONCLUSIONSnHere we present the seventh known case of ectopic thyroid tissue in the adrenal gland and the first case of concomitant incidental PTMC in the setting of this ectopic tissue finding. Using this case, we discuss the diagnostic and therapeutic challenges faced and propose the use of biomarkers to help determine the metastatic potential of these tumors.

Small bowel obstruction in a postpartum woman after laparoscopic Roux-en-Y gastric bypass

OBJECTIVESnThe purpose of our study was to evaluate resident case coverage before and after the implementation of duty-hour restrictions and discuss its potential impact on surgical attendings.nnnDESIGNnWe reviewed cases before (6/2002 to 6/2003) and after (6/2008 to 6/2009) the implementation of duty-hour restrictions, retrospectively.nnnSETTINGnAcademic-affiliated community surgical residency program.nnnPARTICIPANTSnFull-time academic faculty and surgical residents.nnnRESULTSnOf 5253 cases performed in the year before the 80-hour workweek, 4466 (85%) were covered by residents and 787 (15%) were uncovered. Of the 6123 cases performed after the 80-hour workweek restrictions, 3694 (60%) were covered by residents and 2429 (40%) were uncovered. Despite an increase in operations and faculty, significantly fewer cases were covered by residents when comparing the time-restricted and non-time-restricted periods (85% vs 60%, p < 0.005).nnnCONCLUSIONSnThe number of surgical cases without resident participation has increased significantly in the 80-hour workweek. Departments should reevaluate faculty expectations relative to time management, compensation, and nonclinical responsibilities.