Yazan N. AlJamal

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.

Every Surgical Resident Should Know How to Perform a Cricothyrotomy: An Inexpensive Cricothyrotomy Task Trainer for Teaching and Assessing Surgical Trainees

OBJECTIVE Emergency cricothyrotomy is a rare but potentially lifesaving procedure. Training opportunities for surgical residents to learn this skill are limited, and many graduating residents have never performed one during their training. We aimed to develop and validate a novel and inexpensive cricothyrotomy task trainer that can be constructed from household items. DESIGN A model was constructed using a toilet paper roll (trachea and larynx), Styrofoam (soft tissue), cardboard (thyroid cartilage), zip tie (cricoid), and fabric (skin). Participants were asked to complete a simulated cricothyrotomy procedure using the model. They were then evaluated using a 10-point checklist (5 points total) devised by 6 general surgeons. Participants were also asked to complete an anonymous survey rating the educational value and the degree of enjoyment regarding the model. SETTING A tertiary care teaching hospital. PARTICIPANTS A total of 54 students and general surgery residents (11 medical students, 32 interns, and 11 postgraduate year 3 residents). RESULTS All 54 participants completed the training and assessment. The scores ranged from 0 to 5. The mean (range) scores were 1.8 (1-4) for medical students, 3.5 (1-5) for junior residents, and 4.9 (4-5) for senior-level residents. Medical students were significantly outperformed by junior- and senior-level residents (p < 0.001). Trainees felt that the model was educational (4.5) and enjoyable (4.0). CONCLUSIONS A low-fidelity, low-cost cricothyrotomy simulator distinguished the performance of emergency cricothyrotomy between medical students and junior- and senior-level general surgery residents. This task trainer may be ideally suited to providing basic skills to all physicians in training, especially in settings with limited resources and clinical opportunities.

Video Skills Curricula and Simulation: A Synergistic Way to Teach 2-Layered, Hand-Sewn Small Bowel Anastomosis

BACKGROUND We sought to determine if general surgery (GS) interns could learn a side-to-side, 2-layered, hand-sewn small bowel anastomosis (HSBA) using an online instructional video and low-fidelity simulation model. METHODS A 3-hour HSBA technical skills training session was held among GS interns. Participants were asked to write down the steps for performing a side-to-side, 2-layered HSBA (pretest). An online 13-minute instructional video on HSBA was then viewed. Low-fidelity bowel simulators were then provided for deliberate practice under staff supervision. A posttest (identical to pretest) concluded the session. The maximum test score was 20 points. At 4 months later, a retention test was administered. Trainees were anonymously surveyed to determine the sessions educational value. Pretest, posttest, and retention test scores were compared. RESULTS Participants were 25 GS interns. The mean pretest score was 5 (range: 0-11). Posttest scores improved (mean = 15; range: 11-19, p = 0.016), whereas retention test scores were stable (mean = 14; range: 8-18). Of those who participated in retention testing (24/25), 7 had now performed a 2-layered HSBA, 11 had witnessed HSBA, and 6 had neither performed nor witnessed an HSBA since the educational session. Retention test scores were higher among those who had performed HSBA (mean = 16; range: 13-18) vs those who had not performed nor witnessed an HSBA (mean = 14; range: 8-18, p = 0.04). Mean Likert scores supported the educational value of the session. CONCLUSION Initial intern performance of HSBA was abysmal. A contemporary online video skills curriculum coupled with low-fidelity bowel simulators improved trainee knowledge of how to perform a 2-layered HSBA. This effect remained stable over 4 months.

Assimilating endocrine anatomy through simulation: a pre-emptive strike!

BACKGROUND We sought to determine if endocrine anatomy could be learned with the aid of a hands-on, low-cost, low-fidelity surgical simulation curriculum and pre-emptive 60-second YouTube video clip. METHODS A 3-hour endocrine surgery simulation session was held on back-to-back Fridays. A video clip was made available to the 2nd group of learners. A comprehensive 40-point test was administered before (pre-test) and after (post-test) the sessions. RESULTS General surgery interns (n = 26) participated. The video was viewed 19 times by 80% (12 of 15) of interns with access. Viewers outperformed nonviewers on subsequent post-testing (mean [SD], 29.7 [1.3] vs 24.4 [1.6]; P = .015). Mean scores on the anatomy section of the post-test were higher among viewers than nonviewers (mean [SD] 14.2 [.9] vs 10.3 [1.0]; P = .012). CONCLUSIONS Low-cost simulation models can be used to teach endocrine anatomy. Pre-emptive viewing of a 60-second video may have been a key factor resulting in higher post-test scores compared with controls, suggesting that the video intervention improved the educational effectiveness of the session.

Factors that Predict an Intern's First ABSITE Score are Known by September

BACKGROUND Previous studies offer conflicting relevance of a variety of factors to predict resident performance on the The American Board of Surgery In-Training Exam (ABSITE). With numerous stellar applicants scoring poorly on their first ABSITE, we sought to identify key factors that might allow us to tailor pre-emptive study efforts in the fall and early winter to enhance scores. METHODS General Surgery residents in our program from 2009 through 2016 were included in our cohort study. Specific trainee data (sex, prelim vs categorical, United States Medical Licensing Examination (USMLE) Step 1 and 2 scores, ABSITE scores, clinical rotations, biannual objective structured clinical examination OSCE-type scores, and in-house prep test [IHPT], etc.) were collected retrospectively. The data were analyzed using JMP pro 10 and MedCalc. RESULTS ABSITE scores of our 110 trainees did not vary by sex or by categorical vs preliminary residents. USMLE step 1 and 2, IHPT and one objective structured clinical examination (OSCE) station (Sim-Based Trauma Exam) scores were positively correlated with ABSITE scores (p < 0.05; correlation coefficient (CC) = 0.6 [strong] for IHPT, 0.5 [moderate] for step 1 and 2 and [weak] 0.3 for Sim-Based Trauma Exam). The mean (standard deviation) ABSITE %tile score for residents scoring above 230 (USMLE 1 or 2) vs <230 were different: 81 (3) vs 56 (4) (p < 000.1). Of residents scoring lower than 230 in USMLE 1 or 2, their ABSITE performance had a strong positive linear correlation with their performance in the IHPT (CC = 0.7) and SBTA (CC = 0.5). Residents rotating twice on the Acute Care Surgery services before the ABSITE scored higher than those with 1 or zero rotations (p < 0.05). CONCLUSIONS USMLE steps 1 and 2 are useful parameters in our program to predict subsequent resident ABSITE performance. An in-house 60-minute preparation test in September, a 6-minute simulation-based trauma assessment in July, and rotation schedule with 2 stints on Acute Care Surgery were surprisingly useful early intern year tools to predict ABSITE scores.

Maximum cosmesis for patients with primary hyperparathyroidism: a case for larger incisions

Abstract While minimally invasive parathyroidectomy is an advantage to many properly selected patients, longer incisions and even wide skin resection may be optimal in a select few. We present an 80-year-old woman with primary hyperparathyroidism and bothersome excess neck skin and subcutaneous fat. The parathyroid adenoma was easily excised through a vertically-oriented cervical excision that removed an ellipse of fat and skin. Midline wound closure with a small Z-plasty to avoid wound tethering facilitated a cosmetic closure well within the surgical capabilities of endocrine surgeons. This technique is useful for select patients and their surgeons and may avoid the expense of cosmetic surgery. We offer this controversial case to highlight the pros and cons of maximizing efficient surgical care to our endocrine surgery patients.

Forequarter amputation for recurrent breast cancer

Highlights • Forequarter amputation is an aggressive treatment for recurrent breast cancer.• Some patients with regional metastatic disease do benefit from forequarter amputation.• Patients with unrelenting cancer pain do gain relief from forequarter amputation.

Board #147 - Research Abstract Pancreaticoduodenectomy and Hepaticojejunostomy: Simple, Low-cost, and Effective Modeling of Advanced Surgical Techniques (Submission #9933)

Hypothesis General Surgery (GS) residents salivate at the opportunity to participate in major hepatobiliary (HPB) operations. Pancreaticoduodenectomy (PD) along with its associated pancreaticojejunostomy (PJ) and hepaticojejunostomy (HJ) are technically complex procedures which are highly revered and eagerly sought by surgical trainees. Exposure to the basic concepts underlying these procedures in a simulated environment may lead to better understanding of such advanced techniques. We aimed to construct an effective HPB skills session for GS interns using low-cost, low-fidelity models. Methods An inexpensive model was constructed using cardboard, fabric (liver, jejunum), portion of a Penrose drain (common bile duct) and portion of a hot dog (pancreas). GS interns (n=18) initially participated in a 3-hour didactic/simulation session which taught technique for the components of a PD. Residents were then asked to perform a PD with the associated PJ and HJ using the model. Knowledge evaluation was accomplished using a 10-question pre- and post-task written exam. Participants were surveyed anonymously and asked to rate degree of model realism, enjoyment, and educational benefit using a 5-point Likert scale (1= strongly disagree, 5= strongly agree). Results All residents completed the session. Each model cost roughly

Board 409 - Research Abstract Simulating Azygos Vein Ligation - Deliberate Practice is Invaluable (Submission #1187)

1 and required 2-3 minutes for construction. Mean pre-test scores were 5.1 (range 3-8, SD = 1.57). The post-test mean was 6.5 (range 4-9, SD = 1.29; p=0.002). Mean Likert scores were 4.1. Conclusion A simple, low-cost model with an assessment tool can be educationally effective and improve understanding of complex surgical procedures such as HJ and PJ. Participants enjoyed the session and felt the model was realistic. Future research will assess the influence of this model on technical prowess in the operating theater. Disclosures None

Board 302 - Research Abstract Evaluating General Surgery Residents Laparoscopic Skills via Low-Cost, Low-Fidelity Simulation: A Clever Use of Cloth and Felt (Submission #1185)

Introduction/Background General Surgery (GS) residents painstakingly learn to ligate vessels in continuity. Swift and skillful knot tying in the chest is a particular challenge to the burgeoning thoracic surgeon. We sought to assess baseline proficiency in ligating the azygos vein within a simulated chest among GS interns, medical students and thoracic surgery staff. Methods A low-fidelity chest model was constructed in the left lateral decubitus position using cardboard (scapula, ribs and chest wall), fabric (skin, subcutaneous tissue, muscle, fascia, esophagus, vagus and intercostal nerves, lung, mediastinal pleura and superior vena cava) and a 10 mL water filled balloon (azygos vein). GS interns (n = 34), medical students (n = 4) and thoracic surgery staff (n = 2) were asked to ligate the azygos vein in continuity through an eight cm diameter thoracotomy with a depth of 20 cm using 2-0 silk ligatures. Of the 40 participants, only staff surgeons had prior thoracic knot tying training. Scores were based on a 20-point grading scale including task completion, timing and completeness of lumen occlusion. Participants were surveyed anonymously and asked to rate degree of model realism, enjoyment and educational benefit using a 5-point Likert scale (1= strongly disagree, 5= strongly agree). Results Thirty nine of 40 trainees completed the task. The mean score for GS interns was 9.2 (range 3–16, SD = 2.7), medical students 8.5 (range 5-10, SD 2.3, p = 0.54) and thoracic surgeons 18 (SD 0, p = 0.03). Mean task completion times among residents and medical students were slow (133 vs 132 seconds respectively). Staff surgeons were faster (mean = 36 seconds, p = 0.02). Proximal or distal azygos vein stump leaks of any kind occurred in 20% (13/68) of surgical resident veins, 38% (3/8) of medical student veins and none for staff. When azygos stumps were subjected to a force of 22.5N, 33% (4/12) of initial drip leaks worsened to unimpeded flow among surgical residents. Of the veins initially without leak, 2% (1/50) progressed to a detectable drip while 4% (2/50) progressed to unimpeded flow among surgical residents when stump force was applied. Survey response was 80%. Mean Likert scores for usefulness in teaching thoracic knot tying (4.6), utility in learning to tie in other difficult anatomic locations (4.6) and enjoyability (4.2) rated the highest. Trainees and staff felt that the model was acceptable with regards to realism (3.8) and usefulness as a practice tool (4.0). Conclusion This low-fidelity simulator is able to separate novice thoracic knot tiers from experienced surgeons. Participants validate its usefulness as a teaching tool with favorable response. This study further exposes the need for deliberate practice among young trainees. Disclosures None.