Can general surgeons perform laparoscopic surgery independently within 10 years of training? A nationwide survey on laparoscopic surgery training in Japan.

PURPOSE: There is no standard program for laparoscopic surgery training in Japan, and competency in these procedures does not require the acquisition of board certification. The purpose of this survey was to investigate the current status of laparoscopic surgery training in Japan. METHODS: A questionnaire survey was mailed to 2296 members of the Japan Society for Endoscopic Surgery who were between postgraduate year 3 and 10. The questionnaire inquired about laparoscopic surgical training conditions, operation case numbers, and autonomy in eight laparoscopic procedures. RESULTS: The total response rate was 28.1%. The number of cases required to perform procedures independently was demonstrated. Most participants felt confident in performing laparoscopic appendectomy and cholecystectomy; however, they felt less confident about performing laparoscopic colectomy and gastrectomy. CONCLUSIONS: The information from this survey may be useful for surgical educators, surgical societies, and the board certification council for rebuilding the surgical training system in Japan.

Parental preferences in treatment of acute uncomplicated appendicitis comparing surgery to conservative management with antibiotics and their views on research participation.

Studies show that conservative management in acute uncomplicated appendicitis (AUA) is an alternative to surgery. This study aims to determine factors affecting parental preference in management of AUA and their decision for research participation. We conducted surveys on parents whose children were admitted with suspicion of appendicitis but later confirmed not to have appendicitis. Information on appendicectomy versus conservative treatment with antibiotics was provided using a fixed script and standard information leaflet. Questionnaires covered factors influencing decisions, opinions regarding research, treatment preference and demographic data. We excluded parents not fluent in English. Of 113 respondents, 71(62.8%) chose antibiotics, 39(34.5%) chose appendicectomy, and 3(2.7%) had no preference. Reasons given for choosing antibiotics were fear of surgical risks and preferring less invasive treatment. Those choosing appendicectomy expressed preference for definitive treatment and fear of recurrence. Majority were against randomisation (n = 89, 78.8%) and blinding (n = 90, 79.7%). Over half found difficulty involving their child in research (n = 65, 57.5%). Most thought that research is important (66.4%) and beneficial to others (59.3%). Parents who perceived their child as healthy found research riskier (p = 0.039). Educated parents were more likely to find research beneficial to others (p = 0.012) but less accepting of randomisation (p = 0.001).Conclusion: More parents appear to prefer conservative treatment for acute uncomplicated appendicitis. Researchers must consider parental concerns regarding randomisation and blinding.What is Known:• Conservative management of acute uncomplicated appendicitis in paediatric patients is safe and effective, sparing the child the need for an operation; however, neither conservative nor surgical management is proven to be superior.• Randomised controlled trials provide the highest level of evidence, but it is challenging to recruit paediatric patients as participants in such clinical trials.What is New:• More parents prefer conservative management of uncomplicated appendicitis over surgical management for their children due to fear of surgical risks and complications• Randomisation in trial design is significantly associated with a parent's decision to reject their child's participation in a clinical trial.

Patient perspectives on antibiotics for appendicitis at one hospital.

BACKGROUND: Appendicitis has long been considered a progressive inflammatory condition best treated by prompt appendectomy. Recently, several trials comparing initial treatment with antibiotics alone to appendectomy suggest that antibiotic therapy may be a safe option in select patients. However, little is known about patients' understanding of appendicitis, prioritized outcomes, and treatment preferences. MATERIALS AND METHODS: We conducted a prospective, observational survey at a Los Angeles County public hospital emergency department. Trained study coordinators recorded the following data on each subject: basic knowledge of appendicitis, past surgical and antibiotic history, and medical illness outcome priorities. Participants were then educated about appendicitis and were told that studies had demonstrated that appendicitis can be treated safely with antibiotics alone. Subjects were then surveyed as to their preference for urgent surgery or antibiotics alone in a hypothetical scenario of acute uncomplicated appendicitis. RESULTS: Of 129 subjects interviewed, 56 (43%) correctly defined appendicitis, and 69 (53%) identified the treatment for appendicitis as surgery. When presented with a hypothetical acute appendicitis scenario, 57% chose antibiotics over surgery. Persons with previous appendectomy and parents of minors more often chose antibiotics alone, 74% and 63%, respectively. Dying was the most frequently cited and highest-ranked concern about medical illness. CONCLUSIONS: Our results demonstrate that, among persons at one US public hospital, understanding of appendicitis is poor. Once presented with background information about appendicitis and being informed that antibiotics can safely treat appendicitis, many people would prefer an antibiotic approach over appendectomy. Death is the most prioritized concern.

Surgery: a patient's perspective and lessons learnt.

This article discusses a hospital experience from the point of view of a patient, in this case a healthcare worker herself - a dental student. The author relates her experience of a three-day hospital stay and appendectomy, during which time she experienced the breaking of bad news, the consent process, and the importance of good communication - all from the patient's viewpoint.

Charge Awareness Affects Treatment Choice: Prospective Randomized Trial in Pediatric Appendectomy.

OBJECTIVE: To determine whether charge awareness affects patient decisions. BACKGROUND: Pediatric uncomplicated appendicitis can be treated with open or laparoscopic techniques. These 2 operations are considered to have clinical equipoise. METHODS: In a prospective, randomized clinical trial, nonobese children admitted to a children's hospital with uncomplicated appendicitis were randomized to view 1 of 2 videos discussing open and laparoscopic appendectomy. Videos were identical except that only one presented the difference in surgical materials charges. Patients and parents then choose which operation they desired. Videos were available in English and Spanish. A postoperative survey was conducted to examine factors that influenced choice. The trial was registered at ClinicalTrials.gov (NCT 01738750). RESULTS: Of 275 consecutive cases, 100 met enrollment criteria. In the group exposed to charge data (n = 49), 63% chose open technique versus 35% not presented charge data (P = 0.005). Patients were 1.8 times more likely to choose the less expensive option when charge estimate was given (95% confidence interval, 1.17-2.75). The median total hospital charges were $1554 less for those who had open technique (P < 0.001) and $528 less for the group exposed to charge information (P = 0.033). Survey found that 90% of families valued having input in this decision and 31% of patients exposed to charge listed it as their primary reason for their choice in technique. CONCLUSIONS: Patients and parents tended to choose the less expensive but equally effective technique when given the opportunity. A discussion of treatment options, which includes charge information, may represent an unrealized opportunity to affect change in health care spending.

Does aptitude influence the rate at which proficiency is achieved for laparoscopic appendectomy?

BACKGROUND: The attainment of technical competence for surgical procedures is fundamental to a proficiency-based surgical training program. We hypothesized that aptitude may directly affect one's ability to successfully complete the learning curve for minimally invasive procedures. The aim was to assess whether aptitude has an impact on ability to achieve proficiency in completing a simulated minimally invasive surgical procedure. The index procedure chosen was a laparoscopic appendectomy. STUDY DESIGN: Two groups of medical students with disparate aptitude were selected. Aptitude (visual-spatial, depth perception, and psychomotor ability) was measured by previously validated tests. Indicators of technical proficiency for laparoscopic appendectomy were established by trained surgeons with an individual case volume of more than 150. All subjects were tested consecutively on the ProMIS III (Haptica) until they reached predefined proficiency in this procedure. Simulator metrics, critical error scores, and Objective Structured Assessment of Technical Skills (OSATS) scores were recorded. RESULTS: The mean numbers of attempts to achieve proficiency in performing a laparoscopic appendectomy for group A (high aptitude) and B (low aptitude) were 6 (range 4 to 7) and 14 (range 10 to 18), respectively (p < 0.0001). Significant differences were found between the 2 groups for path length (p = 0.014), error score (p = 0.021), and OSATS score (p < 0.0001) at the initial attempt. CONCLUSIONS: High aptitude is directly related to a rapid attainment of proficiency. These findings suggest that resource allocation for proficiency-based technical training in surgery may need to be tailored according to a trainee's natural ability.

A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis.

BACKGROUND/PURPOSE: This study examines the safety and patient satisfaction in discharging children undergoing laparoscopic appendectomy (LapAppy) for acute appendicitis on the day of surgery. METHODS: After institutional review board approval, data were collected prospectively for 158 consecutive patients undergoing LapAppy for simple appendicitis. Time from operation to discharge and complications were analyzed. At follow-up, parents completed a satisfaction survey. The Student t test was used for statistical analysis. RESULTS: Laparoscopic appendectomy was performed in 158 children ranging from age 2 to 19 years (mean, 12 years) over a 6-month period. Single-port, single-instrument LapAppy was possible in 152 patients (96%). Eighty percent of patients (n = 126) were discharged on the day of surgery, a mean of 4.8 hours postoperatively (range, 1-12 hours). Of the remaining 32, 24 (75%) were admitted because the operation ended too late for postoperative discharge; 3 (9%), for medical reasons; and 5 (16%), when the families declined to leave. One hundred nine parents (87%) whose children went home postoperatively stated that they were happy with the expeditious discharge, whereas 17 (13%) felt nervous. In addition, 116 parents (92%) stated that, in retrospect, same-day discharge was preferable, whereas 10 parents (8%) were not sure that it was the best decision. None, however, would insist on admission if faced with the situation again. There were no major complications and no significant difference in the rate of umbilical wound infections for same-day discharge patients (2%) and admitted patients (3%). CONCLUSION: Routine same-day discharge after pediatric LapAppy for acute appendicitis is safe, with good parent satisfaction.

Qualitative and quantitative analysis of women's perceptions of transvaginal surgery.

BACKGROUND: Prior surveys evaluating women's perceptions of transvaginal surgery both support and refute the acceptability of transvaginal access. Most surveys employed mainly quantitative analysis, limiting the insight into the women's perspective. In this mixed-methods study, we include qualitative and quantitative methodology to assess women's perceptions of transvaginal procedures. METHODS: Women seen at the outpatient clinics of a tertiary-care center were asked to complete a survey. Demographics and preferences for appendectomy, cholecystectomy, and tubal ligation were elicited, along with open-ended questions about concerns or benefits of transvaginal access. Multivariate logistic regression models were constructed to examine the impact of age, education, parity, and prior transvaginal procedures on preferences. For the qualitative evaluation, content analysis by independent investigators identified themes, issues, and concerns raised in the comments. RESULTS: The completed survey tool was returned by 409 women (grouped mean age 53 years, mean number of 2 children, 82% ≥ some college education, and 56% with previous transvaginal procedure). The transvaginal approach was acceptable for tubal ligation to 59%, for appendectomy to 43%, and for cholecystectomy to 41% of the women. The most frequently mentioned factors that would make women prefer a vaginal approach were decreased invasiveness (14.4%), recovery time (13.9%), scarring (13.7%), pain (6%), and surgical entry location relative to organ removed (4.4%). The most frequently mentioned concerns about the vaginal approach were the possibility of complications/safety (14.7%), pain (9%), infection (5.6%), and recovery time (4.9%). A number of women voiced technical concerns about the vaginal approach. CONCLUSIONS: As in prior studies, scarring and pain were important issues to be considered, but recovery time and increased invasiveness were also in the "top five" list. The surveyed women appeared to actively participate in evaluating the technical components of the procedures.

Laparoscopic versus open appendectomy--quality of life 7 years after surgery.

BACKGROUND: In spite of the widespread use of laparoscopic appendectomy, there is an ongoing debate on the advantages of this method when compared to open appendectomy. In the evaluation of a postoperative procedure, long-term quality of life is essential. PATIENTS AND METHODS: From 1999 to 2001, 493 patients diagnosed with acute appendicitis were operated in a German general district hospital and included in an observational study. In a median postoperative interval of 7 years, these patients were re-evaluated regarding their quality of life after surgery. A Short-Form 36 Health Survey (SF-36) questionnaire was applied to evaluate the general parameters of quality of life after surgery. This questionnaire was supplemented by an additional self-developed module referring to the appendectomy. The primary outcome was the recommendation of the experienced operating procedure to relatives and friends. RESULTS: A total of 243 patients underwent a laparoscopic procedure: 132 patients were re-evaluated (recovery rate 54%). In the open group, 250 patients were operated: 121 patients were re-evaluated (recovery rate 48%). The median interval from operation to evaluation was 7 years in the laparoscopic group and 7.7 years in the open group. For the primary outcome, patients with laparoscopic appendectomy would significantly more often recommend the procedure than patients with the open operation method. For secondary outcomes, the cosmetic results were judged significantly more favourably in the laparoscopic group. The eight scaled scores of the SF-36 questionnaire did not differ significantly between the two groups. Four patients of the open group and nine patients of the laparoscopic group (including one converted procedure) needed a reoperation because of incisional hernia, adhesions and late infections. CONCLUSION: Patients after laparoscopic appendectomy show a higher degree of satisfaction with their body and their scar than patients after open appendectomy.

Body image and cosmesis after laparoscopic or open appendectomy.

INTRODUCTION: Minimally invasive techniques, such as laparoscopic appendectomy (LA), are thought to produce better cosmetic results. The aim of this study was to evaluate the body image and cosmesis of patients after both LA and open appendectomy (OA). PATIENTS AND METHODS: Between August 2007 and June 2008, patients who underwent LA or OA with the diagnosis of acute appendicitis were invited to participate in the study by filling out the body image questionnaire. Patients with OA who had the Rockey-Davis incision and LA patients who had the operation by 3 trocars (10-mm infraumbilical, 5-mm suprapubic and additional 10 mm left lower quadrant), were included in the study. RESULTS: A total of 38 patients (20 LA, 18 OA) participated in the study. The mean incision size for OA was 3.2 cm (range, 2 to 6 cm), and the mean scores from the body image questionnaire (both body image scale and cosmetic scale) were similar for both groups (P>0.05). No significant complications or changes in self-confidence (preoperative vs. postoperative) were observed in either group (P>0.05). CONCLUSIONS: To our knowledge, there is no study in the literature that evaluates body image and cosmesis using objective methods for LA. Our results showed that LA has no advantage for body image and cosmesis over OA. Furthermore, prospective studies using different tools with a larger sample size are needed to rationalize the use of laparoscopy for appendectomy.

Appendicectomy deferred to a CEPOD list: the patients' opinion.

AIMS: Implementation of NCEPOD guidelines to avoid out-of-hours operating, Junior doctors' 'New Deal' and EWTD have significantly altered surgical practice. Patients admitted 'out of hours', who need an emergency procedure, are often deferred until the next day. We have attempted to assess patients' opinions of this management plan. METHODS: Consecutive patients admitted with uncomplicated appendicitis and operation deferred to the next day according to NCEPOD guidelines were studied. A surgeon, other than the one carrying out the initial assessment, performed the operation on a scheduled morning emergency list. A full explanation was given to patients regarding reasons for deferring operation, and they found out that a different surgeon would be performing their operation. Patients completed a questionnaire post-operatively. RESULTS: 42 patients were studied; median age 24 years (range 17-69); 32 men, 10 women. Thirty presented after 6 p.m. and eight after midnight. The remaining four were admitted during the day. Only one third of the patients recalled reasons for deferred operation with seven not remembering being given an explanation. Two thirds (n=27) of the patients slept poorly pre-operatively, principally due to pain (17) and ward noise (10). Operation on the same night as their admission was the preferred option in 24 patients. All of these slept poorly. Some 22 patients would have preferred the admitting surgeon to have performed their operation; 16 expressed no preference. Only four patients preferred a 'new' surgeon the following day. Of the 42 patients, 28 did not know who had performed their operation. CONCLUSION: Despite being told why their operation was delayed most patients would prefer not to have their procedure delayed. Lack of sleep pre-operatively is a major determinant of patient opinion. Few patients wanted a 'new' surgeon to perform their operation.

Home next day: early discharge of children following appendicectomy.

Fifty-six children in two groups were discharged within 24 hours of an uncomplicated appendicectomy. While the children in the first group (N = 21) were visited by a nurse at home within 24 hours of discharge, the second group (N = 35) just received telephone calls. The cohort was evaluated by telephone interviews two weeks after discharge. All children fulfilling the discharge standards were discharged safely within 24 hours of surgery. Any physical complaints post-discharge were considered minor. The nurses were able to provide reassurance to the families, give advice and deal with minor problems. As a result the families felt safe and reassured, and in only one case did the fragility of parental confidence become obvious. This study has demonstrated the safety of discharging these children within 24 hours of surgery and the value to nursing contacts in enabling the families to care for their children at home.

Dressing size and pain: a prospective trial.

BACKGROUND: Pain is a personal, subjective experience. In the postoperative period, pain may be influenced by patient, pharmacological and environmental factors. In surgery the aim is to reduce pain in this period by educating patients and using adequate analgesia. The aim of the present study was to assess the effect of perceived wound size on pain, as indicated by wound dressing, in the immediate postoperative period. METHODS: Patients undergoing appendicectomy were randomized into a group having a dressing the same size (SSD) as the surgical wound or double the size (DSD) of the wound. Patients' pain perception and analgesic requirements were then recorded and analysed to compare the two groups. RESULTS: Both groups had similar results when comparing pain perception. The median total pain score for the SSD and DSD groups at 12 and 24 h postoperatively revealed no statistically significant difference (P > 0.05). CONCLUSION: The data do not support the hypothesis that postoperative pain may be altered by perceived wound dressing size. Dressing size does not appear to be a variable that could easily be altered to reduce postoperative pain in surgical patients.

Long-term hospital attendance of children and adults who have undergone removal of normal or inflamed appendices.

BACKGROUND: Early studies suggested that presentations with unexplained acute abdominal pain were associated with increased long-term rates of hospital attendance and self-harm, especially in women, but few studies were large enough for definitive findings. AIMS: To test the hypothesis that such presentations are followed by higher long-term utilisation rates of secondary health care even excluding further abdominal symptoms, and particularly for self-harm, than presentations with acute appendicitis. METHOD: New hospital attendance rates, liaison psychiatry attendances and self-harm attendances of patients with normal appendices at emergency appendicectomy were compared with those of appendicitis patients. RESULTS: Attendance rates of all kinds were significantly higher for normal appendix patients than for appendicitis patients, with equal strengths of finding for males and females. CONCLUSIONS: People with normal appendices at emergency appendicectomy show higher long-term rates of hospital attendance. This has implications for how these patients are best managed by health care systems.

[Psychological aspects in surgery--surgical aspects in psychology: psychosomatic medicine in routine practice?]. / Seelisches in der Chirurgie--Chirurgisches in der Seele: Psychosomatik im chirurgischen Alltag?

Medicine appears to have reached a standstill, in particular surgery: While progress in apparative diagnostics and therapy, e.g. by ultrasound, endoscopy, laparoscopy, and arthroscopy, has reached in some areas "breathtaking speed", the parties concerned-surgeons and patients-lose in reserve air to breathe: no time for any profound consideration, no chance for in-depth talking before surgical procedures are performed, no training for giving real support after surgery. Do we see a brand of surgery which feels responsible only for a human machine without soul? Meanwhile discussions have begun inside medicine in general about a change of paradigms, ways of thinking, the model of the world. Surgery can even make substantial contributions to this change of paradigms. Surgery for the human machine? Psychosomatic ways of thinking are first seen not applicable for surgery. Substantial anxiety exists to take notice of each other. Three concrete examples from everyday practice in surgery demonstrate, how psychosomatic thinking can change and enrich surgical practice: From the area of indications reflections about appendectomy, from the operative-surgical area the phenomenon of self-destructive behaviour, from the restitutive area experiences in treatment of osteomyelitis. Back to the interpersonal area! Psychosomatics must be recognised as a way of thinking and be integrated as such into surgery. A so-called "integrated surgery" will arise. The examples demonstrate also, that it is not some anonymous surgical medicine, which must and can change, but that only the individual surgeon as a concrete person can bring back his work into the interpersonal area.

Behavioral disturbances in children after trauma.

The psychological effects of nonneurologic trauma on children are poorly recognized. We hypothesized that physical trauma in children, with or without head injury, would result in substantial and persistent psychological and behavioral abnormalities. Using a short telephone survey followed by a detailed behavioral checklist, we studied psychobehavioral dysfunction in children who had experienced trauma either with or without minor head injury (n = 40 each) as well as in a comparative group of children after emergency appendectomy (n = 80). Substantial behavioral disability was identified by the detailed checklist in 35% and 28% of children without and with head injury, respectively, but in none after appendectomy. Dysfunctions included phobias, major scholastic difficulties, rage attacks, and episodic depression that continued for a long period. Even in the 67% of children who eventually fully recovered, the duration of symptoms after the time of injury was an average of 19 months. Demographics, socioeconomic status, severity of injury, and length of hospitalization did not correlate with dysfunction, and these traumatized children's siblings had no reported history of trauma or psychological difficulties. Thus, parental opinion about behavioral dysfunction appears sensitive and specific and is therefore a useful screening index. These results suggest that injured children, even after minor trauma, may suffer substantial and long-lasting behavioral changes to a degree hitherto unrecognized.