Evaluation of Long-Term Nutrition Outcomes After Duodenal Switch: A Systematic Review and Meta-Analysis.

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD-DS) is the most effective and durable metabolic and bariatric surgery to achieve a target weight loss. However, many surgeons are hesitant to adopt BPD-DS due to a lack of training, technical complexity, and long-term nutrition deficiencies. This meta-analysis aimed to investigate long-term nutrition outcomes after primary BPD-DS in the management of obesity. METHODS: Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to February 2023 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42023391316). RESULTS: From 834 studies screened, 8 studies met the eligibility criteria, with a total of 3443 patients with obesity undergoing primary BPD-DS. At long-term follow-up (≥5 years), 25.4% of patients had vitamin A deficiency (95% CI: -.012, .520, I2 = 94%), and 57.3% had vitamin D deficiency (95% CI: .059, 1.086, I2 = 86%). Calcium deficiency was observed in 125 patients (22.2%, 95% CI: .061, .383, I2 = 97%), and 69.7% had an abnormal parathyroid hormone level (95% CI: .548, .847, I2 = 78%). Ferritin level was abnormal in 30 patients (29.0%, 95% CI: .099, .481, I2 = 79%). CONCLUSIONS: Despite displaying comparable nutrition-related outcomes to mid-term follow-up, our study demonstrated that BPD-DS could result in a high level of long-term nutrition deficiency after BPD-DS for selected patients. However, further randomized controlled studies with standardized supplementation regimens and improvement in compliance are necessary to evaluate and prevent long-term nutritional deficiencies after BPD-DS.

Utilizing Simulation to Evaluate Robotic Skill Acquisition and Learning Decay.

BACKGROUND: We aim to evaluate how new robotic skills are acquired and retained by having participants train and retest using exercises on the robotic platform. We hypothesized that participants with a 3-month break from the robotic platform will have less learning decay and increased retention compared with those with a 6-month break. METHODS: This was a prospective randomized trial in which participants voluntarily enrolled and completed an initial training phase to reach proficiency in 9 robot simulator exercises. They were then instructed to refrain from practicing until they retested either 3 or 6 months later. This study was completed at an academic medical center within the general surgery department. Participants were medical students, and junior-level residents with minimal experience in robotic surgery were enrolled. A total of 27 enrolled, and 13 participants completed the study due to attrition. RESULTS: Overall, intragroup analysis revealed that participants performed better in their retest phase compared with their initial training in terms of attempts to reach proficiency, time for completion, penalty score, and overall score. Specifically, during the first attempt in the retesting phase, the 3-month group did not deviate far from their final attempt in the training phase, whereas the 6-month group experienced significantly worse time to complete and overall score in interrupted suturing {[-4 (-18 to 20) seconds vs. 109 (55 to 118) seconds, P =0.02] [-1.3 (-8 to 1.9) vs. -18.9 (-19.5 to (-15.0)], P =0.04} and 3-arm relay {[3 (-4 to 23) seconds vs. 43 (30 to 50) seconds, P =0.02] [0.4 (-4.6 to 3.1) vs. -24.8 (-30.6 to (-20.3)], P =0.01] exercises. In addition, the 6-month group had a significant increase in penalty score in retesting compared with the 3-month group, which performed similarly to their training phase [3.3 (2.7 to 3.3) vs. 0 (-0.8 to 1.7), P =0.03]. CONCLUSIONS: This study identified statistically significant differences in learning decay, skills retention, and proficiency between 3-month and 6-month retesting intervals on a robotic simulation platform.

S136-operationalizing an enhanced recovery protocol after bariatric surgery: single institutional pilot experience forging data-driven standard work.

BACKGROUND: Enhanced recovery protocols (ERPs) after metabolic and bariatric surgery (MBS) may help decrease length of stay (LOS) and postoperative nausea/vomiting but implementation is often fraught with challenges. The primary aim of this pilot study was to standardize a MBS ERP with a real-time data support dashboard and checklist and assess impact on global and individual element compliance. The secondary aim was to evaluate 30 day outcomes including LOS, hospital readmissions, and re-operations. METHODS AND PROCEDURES: An ERP, paper checklist, and virtual dashboard aligned on MBS patient care elements for pre-, intra-, and post-operative phases of care were developed and sequentially deployed. The dashboard includes surgical volumes, operative times, ERP compliance, and 30 day outcomes over a rolling 18 month period. Overall and individual element ERP compliance and outcomes were compared pre- and post-implementation via two-tailed Student's t-tests. RESULTS: Overall, 471 patients were identified (pre-implementation: 193; post-implementation: 278). Baseline monthly average compliance rates for all patient care elements were 1.7%, 3.7%, and 6.2% for pre-, intra-, and post-operative phases, respectively. Following ERP integration with dashboard and checklist, the intra-operative phase achieved the highest overall monthly average compliance at 31.3% (P < 0.01). Following the intervention, pre-operative acetaminophen administration had the highest monthly mean compliance at ≥ 99.1%. Overall TAP block use increased 3.2-fold from a baseline mean rate of 25.4-80.8% post-implementation (P < 0.01). A significant decrease in average intra-operative monthly morphine milligram equivalents use was noted with a 56% drop pre- vs. post-implementation. Average LOS decreased from 2.0 to 1.7 days post-implementation with no impact on post-operative outcomes. CONCLUSION: Implementation of a checklist and dashboard facilitated ERP integration and adoption of process measures with many improvements in compliance but no impact on 30 day outcomes. Further research is required to understand how clinical support tools can impact ERP adoption among MBS patients.

A prospective, multicenter trial of a long-term bioabsorbable mesh with Sepra technology in cohort of challenging laparoscopic ventral or incisional hernia repairs (ATLAS trial).

BACKGROUND: This prospective, multicenter, single-arm, open-label study evaluated P4HB-ST mesh in laparoscopic ventral or incisional hernia repair (LVIHR) in patients with Class I (clean) wounds at high risk for Surgical Site Occurrence (SSO). METHODS: Primary endpoint was SSO requiring intervention <45 days. Secondary endpoints included: surgical procedure time, length of stay, SSO >45 days, hernia recurrence, device-related adverse events, reoperation, and Quality of Life at 1, 3, 6, 12, 18, and 24-months. RESULTS: 120 patients (52.5% male), mean age of 55.0 ± 14.9 years, and BMI of 33.2 ± 4.5 kg/m2 received P4HB-ST mesh. Patient-reported comorbid conditions included: obesity (86.7%), active smoker (45.0%), COPD (5.0%), diabetes (16.7%), immunosuppression (2.5%), coronary artery disease (7.5%), chronic corticosteroid use (2.5%), hypoalbuminemia (0.8%), advanced age (10.0%), and renal insufficiency (0.8%). Hernia types were primary ventral (44.2%), primary incisional (37.5%), recurrent ventral (5.8%), and recurrent incisional (12.5%). Patients underwent LVIHR in laparoscopic (55.8%) or robotic-assisted cases (44.2%), mean defect size 15.7 ± 28.3 cm2, mean procedure time 85.9 ± 43.0 min, and mean length of stay 1.0 ± 1.4 days. There were no SSOs requiring intervention beyond 45 days, n = 38 (31.7%) recurrences, n = 22 (18.3%) reoperations, and n = 2 (1.7%) device-related adverse events (excluding recurrence). CONCLUSION: P4HB-ST mesh demonstrated low rates of SSO and device-related complications, with improved quality of life scores, and reoperation rate comparable to other published studies. Recurrence rate was higher than expected at 31.7%. However, when analyzed by hernia defect size, recurrence was disproportionately high in defects ≥7.1 cm2 (43.3%) compared to defects <7.1 cm2 (18.6%). Thus, in LVIHR, P4HB-ST may be better suited for small defects. Caution is warranted when utilizing P4HB-ST in laparoscopic IPOM repair of larger defects until additional studies can further investigate outcomes.

Pharmacy-led initiative for improving peri-operative medication reconciliation among bariatric surgical patients: what is the role?

BACKGROUND: Multiple medication changes are common after bariatric surgery, but pharmacist assistance in this setting is not well described. This study evaluated the feasibility and effectiveness of a pharmacy-led initiative for facilitating discharge medicine reconciliation after bariatric surgery. METHODS: A standardized post-operative pharmacy consult evaluation was conducted on bariatric surgery inpatients at a single academic center starting 1/2/2019. Retrospective chart review evaluated patient characteristics, medication changes, and 30-day outcomes pre-intervention (7/2018-12/2018) and post-intervention (1/2019-12/2019). Two-sample t tests or binomial tests were used for continuous or categorical variables, respectively; a p-value of < 0.05 was deemed statistically significant. RESULTS: A total of 353 patients were identified for study inclusion (n = 158 pre-intervention, n = 195 post-intervention) with a mean age of 45 years, 87% female, and 71% sleeve gastrectomy. Overall pharmacy consultation compliance was 94% with 77.0% of home medication recommendations followed. Non-narcotic pain medication prescription use significantly increased (39% pre- vs. 54% post-intervention; p < 0.001). At discharge, the average number of changed or new medications significantly increased (3.7 ± 1.2 pre- vs. 4.2 ± 1.8 post-intervention; p = 0.003) while the average number of stopped medications was similar (1.2 ± 1.5 pre- vs. 1.5 ± 1.9 post-intervention; p = 0.09). Anti-hypertensive medications were decreased or stopped substantially more often with pharmacist input (44.7% pre- vs. 85.4% post-intervention; p < 0.001). Three medication-related readmissions happened pre-intervention with none post-intervention. Outpatient medication-related phone calls did considerably increase (31% pre- vs. 39% post-intervention; p = 0.04), while overall 30-day readmissions significantly decreased (7.6% pre- vs. 1.5% post-intervention; p = 0.04). CONCLUSIONS: Inpatient pharmacy consultation facilitated rapid alteration to more appropriate therapy for hypertension management and significantly increased use of non-narcotic pain medications upon discharge among bariatric surgery patients. Improved protocol adherence is anticipated with program maturity and patient education interventions will be deployed to address outpatient phone calls.

Development of a laparoscopic surgical skills simulation curriculum: Enhancing resident training through directed coaching and closed-loop feedback.

BACKGROUND: Performance feedback through peer coaching and rigorous self-assessment is a critical part of technical skills improvement. However, formal collaborative programs using operative video-based skills assessments to generate peer coaching feedback have only been validated among attending surgeons. In this study, we developed a unique longitudinal, simulation video-based laparoscopic skills resident curriculum using video-based peer coaching and evaluated its association with skills acquisition among surgical trainees. METHODS: The laparoscopic simulation curriculum consists of a pre-practice laparoscopic skill video recording, followed by receipt of directed coaching and feedback on performance from a faculty coach, a peer coach, and self-coaching. Residents then completed 6 weeks of feedback-directed practice and submitted a second post-practice laparoscopic skill video recording of the same skill, which was evaluated by a minimally invasive surgery expert grader. All general surgery residents in a single institution were enrolled, with 107 residents completing the curriculum in its initial 2 years. RESULTS: Overall, more than two-thirds of residents achieved skills proficiency on their expert assessments, with similar rates of residents achieving skills proficiency at all postgraduate year levels. Significant improvements between the pre-practice assessments and post-practice assessments were most frequently seen in the instrument handling, precision, and motion & flow categories (P < .05 each). Faculty provided the highest number and proportion of closed-loop comments; residents' self-coaching feedback had the lowest number of closed-loop comments, with 83% of self-assessments containing none. CONCLUSION: In this study, we describe the successful implementation of a longitudinal laparoscopic skills video-based coaching curriculum designed to improve residents' laparoscopic technical abilities through iterative directed practice supplemented by formative closed-loop feedback. This feasible, reproducible, and low-cost simulation curriculum can be adapted to other training programs and skills acquisition endeavors. This program also prepares trainees for ongoing performance feedback after completion of residency through rigorous self-assessment and peer-to-peer coaching.

Laparoscopic Hunt-Lawrence Jejunal Pouch for Reconstruction After Total Gastrectomy for Gastric Cancer.

Background: There are several reconstruction options described in the literature after total gastrectomy for gastric cancer. The most common laparoscopic jejunal pouch technique involves evisceration of the small bowel and extracorporeal pouch formation. Methods: We describe a completely intracorporeal technique for the Hunt-Lawrence J-pouch Roux-en-Y reconstruction. After gastrectomy and formation of the Roux limb, we create the esophagojejunal anastomosis using an end-to-end anastomosis (EEA) stapler threaded 6-7 cm into the Roux limb to leave a tail of jejunum for the pouch. Next we form the jejunal pouch with a linear stapler and close the common enterotomy with suture or stapler. Conclusion: Our technique offers a streamlined and efficient approach to the Hunt-Lawrence reconstruction and can be effectively performed both laparoscopically and robotically.

Post-operative outcomes for patients with liver-related ascites undergoing non-emergent laparoscopic cholecystectomy.

INTRODUCTION: Surgical procedures in patients with cirrhosis and associated ascites carry significant morbidity and mortality. However, these patients often undergo non-emergent but necessary procedures such as laparoscopic cholecystectomy. The purpose of this study is to determine the impact of cirrhosis with ascites on non-emergent laparoscopic cholecystectomy. METHODS: The ACS-NSQIP database was queried from 2005 to 2017 for patients undergoing non-emergent laparoscopic cholecystectomy with or without intra-operative cholangiogram. Groups were propensity score matched for age, sex, BMI, smoking, inpatient status, ASA Class, presence of pre-operative SIRS/sepsis, and the individual components of the 5-item modified frailty index. RESULTS: 346,105 patients were identified, 591 of which who had liver-related ascites. Patients without ascites were matched at a 5:1 ratio, producing 2955 controls. Patients with ascites had significantly higher rates of overall morbidity (15.6% vs. 11.3%, p = 0.0039), mortality (3.6% vs. 1.5%, p = 0.0020), and longer hospitalizations (7.4 vs. 4.4 days, p < 0.0001). Patients with ascites and a MELD score less than or equal to 9 had no difference in morbidity (p = 0.1124) or mortality (p = 0.6021) when compared to patients without ascites. Patients with ascites and a MELD score greater than 9 had significantly higher rates of both morbidity (25.8%, p = 0.0056) and mortality (7.1%, p = 0.0333). CONCLUSION: Patients with cirrhosis and ascites have many comorbidities in addition to their liver disease. These patients are at significant risk for both morbidity and mortality related to non-emergent laparoscopic cholecystectomy. Surgeons should proceed with caution for patients with ascites and MELD scores greater than 9. These cases should only be performed by surgeons comfortable with difficult gallbladders at facilities equipped to take care of cirrhotic patients.

Utilizing functional lumen imaging probe in directing treatment for post-fundoplication dysphagia.

BACKGROUND: Esophagogastric junction obstruction (EGJO) post-fundoplication (PF) is difficult to identify with currently available tests. We aimed to assess the diagnostic accuracy of EGJ opening on functional lumen imaging probe (FLIP) and dilation outcome in FLIP-detected EGJO in PF dysphagia. METHODS: We prospectively collected data on PF patients referred to Esophageal Clinic over 18 months. EGJO diagnosis was made by (a) endoscopist's description of a narrow EGJ/wrap area, (b) appearance of wrap obstruction or contrast/tablet retention on esophagram, or (c) EGJ-distensibility index (DI) < 2.8 mm2/mmHg on real-time FLIP. In patients with EGJO and dysphagia, EGJ dilation was performed to 20 mm, 30 mm, or 35 mm in a stepwise fashion. Outcome was assessed as % dysphagia improvement during phone call or on brief esophageal dysphagia questionnaire (BEDQ) score. RESULTS: Twenty-six patients were included, of whom 17 (65%) had a low EGJ-DI. No patients had a hiatal hernia greater than 3 cm. Dysphagia was the primary symptom in 17/26 (65%). In 85% (κ = 0.677) of cases, EGJ assessment (tight vs. open) was congruent between the combination of endoscopy (n = 26) and esophagram (n = 21) vs. EGJ-DI (n = 26) on FLIP. Follow-up data were available in 11 patients who had dilation based on a low EGJ-DI (4 with 20 mm balloon and 7 with ≥ 30 mm balloon). Overall, the mean % improvement in dysphagia was 60% (95% CI 37.7-82.3%, p = 0.0001). Nine out of 11 patients, including 6 out of 7 undergoing pneumatic dilation, had improvement ≥ 50% in dysphagia (mean % improvement 72.2%; 95% CI 56.1-88.4%, p = 0.0001). CONCLUSIONS AND INFERENCES: Functional lumen imaging probe is an accurate modality for evaluating for EGJ obstruction PF. FLIP may be used to select patients who may benefit from larger diameter dilation.

A scalable tool for adjudication of time sensitive cases during COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, prioritization of care and utilization of scarce resources are daily considerations in healthcare systems that have never experienced these issues before. Elective surgical cases have been largely postponed, and surgery departments are struggling to correctly and equitably determine which cases need to proceed. A resource to objectively prioritize and track time sensitive cases would be useful as an adjunct to clinical decision-making. METHODS: A multidisciplinary working group at Emory Healthcare developed and implemented an adjudication tool for the prioritization of time sensitive surgeries. The variables identified by the team to form the construct focused on the patient's survivability according to actuarial data, potential impact on function with delay in care, and high-level biology of disease. Implementation of the prioritization was accomplished with a database design to streamline needed communication between surgeons and surgical adjudicators. All patients who underwent time sensitive surgery between 4/10/20 and 6/15/20 across 5 campuses were included. RESULTS: The primary outcomes of interest were calculated patient prioritization score and number of days until operation. 1767 cases were adjudicated during the specified time period. The distribution of prioritization scores was normal, such that real-time adjustment of the empiric algorithm was not required. On retrospective review, as the patient prioritization score increased, the number of days to the operating room decreased. This confirmed the functionality of the tool and provided a framework for organization across multiple campuses. CONCLUSIONS: We developed an in-house adjudication tool to aid in the prioritization of a large cohort of canceled and time sensitive surgeries. The tool is relatively simple in its design, reproducible, and data driven which allows for an objective adjunct to clinical decision-making. The database design was instrumental in communication optimization during this chaotic period for patients and surgeons.

Normalized Competitive Index: Analyzing Trends in Surgical Fellowship Training Over the Past Decade (2009-2018).

OBJECTIVE: There is a lack of literature describing how competitive surgical fellowships are, especially across specialties. Such information would be valuable to prospective candidates, especially as immediate postresidency subspecialty training becomes the norm for general surgery. Match-rates alone may be misleading indicators as programs may not fill positions with unqualified applicants. We propose a simple metric to analyze the competitiveness of various surgical subspecialties to each other and themselves over time. DESIGN: Retrospective cohort study. The Competitive Index is defined as the percentage of filled programs within each specialty divided by the match-rate for that specialty. For ease of comparison, a Normalized Competitive Index (NCI) was developed, normalizing the metric for all specialties in that year to a value of 1. SETTING: The National Resident Matching Program, The Fellowship Council, and the San Francisco Match publicly available match data from 2009 to 2018. PARTICIPANTS: General Surgery Associated Fellowship Applicants (Abdominal Transplant, Colorectal, Surgical Oncology, Minimally Invasive Surgery, Pediatric, Plastic, Critical Care, Thoracic, and Vascular). RESULTS: The overall match rate for all specialties was 74.6% and 84.0% of all programs were filled. Over the past decade, pediatric surgery was significantly more competitive than other specialties (NCI 1.67, p < 0.0001), while surgical critical care (NCI 0.58, p < 0.0001) and vascular (NCI 0.90, p < 0.0492) were significantly less competitive. When comparing the NCI within each specialty from the first 5 years (2009-2013) to the last 5 years, (2014-2018), surgical critical care (NCI 0.54 vs. 0.62, p = 0.0462) and thoracic (NCI 0.74 vs. 1.08, p=0.0025) became significantly more competitive, while transplant (NCI 1.10 vs. 0.92, p = 0.0343) and colorectal (NCI 1.32 vs. 1.09, p = 0.0021) became significantly less competitive. CONCLUSION: The NCI is a metric which might be useful to prospective applicants and which could be provided annually by organizations sponsoring fellowship matching processes. Further research must be performed to establish what defines a qualified applicant in each specialty.

Fibrin versus cyanoacrylate glue for fixation in laparoscopic inguinal hernia repair: a network meta-analysis and indirect comparison.

INTRODUCTION: Evidence has demonstrated that biosynthetic glue for laparoscopic inguinal hernia repair results in decreased pain. However, the two glue sub-types (biologic-fibrin based; synthetic-cyanoacrylate based) have never been compared. This study aims to assess the outcomes of those subtypes. METHOD AND PROCEDURES: A systematic review of the MEDLINE database was undertaken. Randomized trials assessing the outcomes of laparoscopic inguinal hernia repair with penetrating and glue fixation methods were considered for inclusion and data analysis. Thirteen trials involving 1947 laparoscopic inguinal hernia repairs were identified with eight trials utilizing fibrin and five trials utilizing cyanoacrylate. RESULTS: There were no differences in recurrence or wound infection between the glue subtypes when compared individually to penetrating fixation alone or indirectly to each other. There were non-significant trends in reduction of hematoma and seroma for both glue subtypes when compared to penetrating fixation (OR 0.73, 95% CI 0.39-1.40). There was a significant reduction in urinary retention with glue fixation (pooled results of both sub-types) when compared to penetrating fixation (OR 0.33, 95% CI 0.13-0.83). CONCLUSIONS: Glue fixation in laparoscopic inguinal hernia repair reduces the incidence of urinary retention and may reduce the rate of hematoma or seroma formation. As there are no differences in outcomes when comparing fibrin or cyanoacrylate glue, surgeons should choose the glue that is available at the lowest cost at their respective institutions.

Laparoscopic Sleeve Gastrectomy Outcomes in Patients with Polycystic Ovary Syndrome.

Polycystic ovary syndrome (PCOS) is a common disease among the bariatric population. However, there are limited data regarding the impact of laparoscopic sleeve gastrectomy (SG) on these patients. The study was conducted at University Hospital, United States. The purpose of this study was to examine per cent excess body weight loss (%EWL) and diabetes control in patients who have PCOS compared with those without PCOS. A total of 550 female patients underwent SG between December 2011 and October 2016. Retrospective analysis was completed to include follow-up data at 1, 3, 6, and 12 months and yearly after that. Outcomes measured were %EWL and hemoglobin A1c (HgbA1c). The mean and median follow-up for the entire cohort was 21 and 15 months, respectively. Seventy-eight per cent of patients completed at least 12 months of follow-up for %EWL, although only 21 per cent had similar follow-up for HgbA1c. PCOS patients had similar age (36.3 vs 36.2 years, P = 0.90), preoperative BMI (47.2 vs 47.2, P = 0.99), preoperative HgbA1c (6% vs 5.8%, P = 0.31), conversion rate to gastric bypass, and other associated comorbidities compared with non-PCOS comparisons. There was no difference in %EWL at 12-month (49.7% vs 53.1%, P = 0.53) or 24-month (43% vs 49.8%, P = 0.46) postoperative intervals. There was no difference in absolute change of HgbA1c at 12 months (-0.47% vs -0.67%, P = 0.39). SG has equivalent short-term results in %EWL and reduction in HgbA1c for patients who have PCOS and those who do not.

Academic inertia: Examining changes of scholarly output over time among academic minimally invasive surgeons.

INTRODUCTION: The purpose of this study is to assess how the Hirsch Index (h-index) and other academic metrics change over time for academic minimally invasive surgeons (MIS). METHODS: Through the Fellowship Council's website, MIS program-directors and associate program-directors were identified in 2017 and again in 2018. Using the Scopus database, the number of publications, citations, self-citations, and h-indices were calculated. RESULTS: A total of 222 surgeons were included. The median increase of publications, citations, and h-index were 4, 134, and 1, respectively. 75% of surgeons (166/222) saw their h-index increase. In 2017, 26% of surgeons (57/222) had an increase of their h-index due to self-citation. One-year later, 35% of those surgeons (20/57) no longer demonstrated that change. CONCLUSION: Self-citation remains infrequent within MIS. The h-index of most surgeons will increase over one-year. Many surgeons demonstrating an increase in h-index due to self-citation will see that change eliminated over time.

Publication patterns and the impact of self-citation among minimally invasive surgery fellowships.

INTRODUCTION: The h-index is a widely utilized academic metric that measures both productivity and citation impact. The purpose of this study is to define the impact of self-citation among minimally invasive surgery (MIS) fellowship program directors. METHODS: Through the Fellowship Council's website, all program directors and associate program directors from the 148 MIS fellowship programs were identified. Using the Scopus database, we calculated the number of publications, citations, self-citations, and h-index for each surgeon. RESULTS: A total of 274 surgeons were identified. The mean number±SD of publications, citations, and h-index for the cohort were 60.5 ±â€¯77.2, 1765 ±â€¯4024, and 16.0 ±â€¯15.0, respectively. The self-citation rate for the entire cohort was 3.23%. Excluding self-citations reduces the mean number of citations to 1708 ±â€¯3887 and h-index to 15.8 ±â€¯14.6. The h-index remained unchanged for 77% (210/274) of surgeons. Only 5% (15/274) of surgeons had a change in h-index of greater than one integer and no surgeon had a change greater than three integers. CONCLUSION: Self-citation is infrequent and has a minimal impact on the academic profile of program directors of MIS fellowships.