Robotic-assisted reoperative ileal pouch-anal anastomosis: robotic pouch excision and pouch revision.

BACKGROUND: Up to 20% of patients with ileal pouch will develop pouch failure, ultimately requiring surgical reintervention. As a result of the complexity of reoperative pouch surgery, minimally invasive approaches were rarely utilized. In this series, we present the outcomes of the patients who underwent robotic-assisted pouch revision or excision to assess its feasibility and short-term results. METHODS: All the patients affected by inflammatory bowel diseases and familial adenomatous polyposis who underwent robotic reoperative surgery of an existing ileal pouch were included. RESULTS: Twenty-two patients were included; 54.6% were female. The average age at reoperation was 51 ± 16 years, with a mean body mass index of 26.1 ± 5.6 kg/m2. Fourteen (63.7%) had a diagnosis of ulcerative colitis at reoperation, and seven (31.8%) had Crohn's disease. The mean time to pouch reoperation was 12.8 ± 11.8 years. Seventeen (77.3%) patients underwent pouch excision, and five (22.7%) had pouch revision surgery. The mean operative time was 372 ± 131 min, and the estimated blood loss was 199 ± 196.7 ml. The conversion rate was 9.1%, the 30-day morbidity rate was 27.3% (with only one complication reaching Clavien-Dindo grade IIIB), and the mean length of stay was 5.8 ± 3.9 days. The readmission rate was 18.2%, the reoperation rate was 4.6%, and mortality was nihil. All patients in the pouch revisional group are stoma-free. CONCLUSION: Robotic reoperative pouch surgery in highly selected patients is technically feasible with acceptable outcomes.

STOPS: A Coping Framework for Surgeons Who Experience Intraoperative Error.

OBJECTIVE: To investigate the steps faculty surgeons take upon experiencing intraoperative error and synthesize these actions to offer a framework for coping with errors. BACKGROUND: While intraoperative errors are inevitable, formal training in error recovery is insufficient and there are no established curricula that teach surgeons how to deal with the intraoperative error. This is problematic because insufficient error recovery is detrimental to both patient outcomes and surgeon psychological well-being. METHODS: We conducted a thematic analysis. One-hour in-depth semistructured interviews were conducted with faculty surgeons from 3 hospitals. Surgeons described recent experiences with intraoperative error. Interviews were transcribed and coded. Analysis allowed for development of themes regarding responses to errors and coping strategies. RESULTS: Twenty-seven surgeons (30% female) participated. Upon completion of the analysis, themes emerged in 3 distinct areas: (1) Exigency, or a need for training surgical learners how to cope with intraoperative errors, (2) Learning, or how faculty surgeons themselves learned to cope with intraoperative errors, and (3) Responses, or how surgeons now handle intraoperative errors. The latter category was organized into the STOPS framework: Intraoperative errors could produce STOPS: Stop, Talk to your Team, Obtain Help, Plan, Succeed. CONCLUSIONS AND RELEVANCE: This study provides both novel insight into how surgeons cope with intraoperative errors and a framework that may be of great use to trainees and faculty alike.

Intraoperative Fluid Management a Modifiable Risk Factor for Surgical Quality - Improving Standardized Practice.

OBJECTIVE: We aimed to determine a safe zone of intraoperative fluid management associated with the lowest postoperative complication rates without increased acute kidney injury (AKi) risk for elective colorectal surgery patients. BACKGROUND: To date, standard practice within institutions, let alone national expectations related to fluid administration, are limited. This fact has perpetuated a quality gap. METHODS: Elective colorectal surgeries between 2018 and 2020 were included. Unadjusted odds ratios (ORs) for postoperative ileus, prolonged LOS, and AKi were plotted against the rate of intraoperative RL infusion (mL/ kg/h) and total intraoperative volume. Binary logistic regression analysis, including fluid volumes as a confounder, was used to identify risk factors for postoperative complications. RESULTS: A total of 2900 patients were identified. Of them, 503 (17.3%) patients had ileus, 772 (26.6%) patients had prolonged LOS, and 240 (8.3%) patients had AKI. The intraoperative fluid resuscitation rate (mg/kg/h) was less impactful on postoperative ileus, LOS, and AKI than the total amount of intraoperative fluid. A total fluid administration range between 300 mL and 2.7 L was associated with the lowest complication rate. Total intraoperative RL ≥2.7 L was independently associated with a higher risk of ileus (adjusted OR 1.465; 95% confidence interval 1.154-1.858) and prolonged LOS (adjusted OR 1.300; 95% confidence interval 1.047-1.613), but not AKI. Intraoperative RL ≤300 mL was not associated with an increased risk of AKI. CONCLUSION: Total intraoperative RL ≥2.7 L was independently associated with postoperative ileus and prolonged LOS in elective colorectal surgery patients. A new potential standard for intraoperative fluids will require anesthesia case planning (complexity and duration) to ensure total fluid volume meets this new opportunity to improve care.

Emergent and Urgent Surgery for Ulcerative Colitis in the United States in the Minimally Invasive and Biologic Era.

BACKGROUND: Although the overall adoption of minimally invasive surgery in the nonemergent management of ulcerative colitis is established, little is known about its utilization in emergency settings. OBJECTIVE: The goal of this study was to assess rates of urgent and emergent surgery over time in the era of emerging biologic therapies and to highlight the current practice in the United States regarding the utilization of minimally invasive surgery for urgent and emergent indications for ulcerative colitis. DESIGN: This was a retrospective analysis study. SETTINGS: Data were collected from the American College of Surgeons National Quality Improvement Program database. PATIENTS: All adult patients who underwent emergent or urgent colectomy for ulcerative colitis were included. MAIN OUTCOME MEASURES: Rates of emergency operations over time and utilization trends of minimally invasive surgery in urgent and emergent settings were assessed. Unadjusted and adjusted overall, surgical, and medical 30-day complication rates were compared between open and minimally invasive surgery. RESULTS: A total of 2219 patients were identified. Of those, 1515 patients (68.3%) underwent surgery in an urgent setting and 704 (31.7%) as an emergency. Emergent cases decreased over time (21% in 2006 to 8% in 2018; p < 0.0001). However, the rate of urgent surgeries has not significantly changed (42% in 2011 to 46% in 2018; p = 0.44). Minimally invasive surgery was offered to 70% of patients in the urgent group (1058/1515) and 22.6% of emergent indications (159/704). Overall, minimally invasive surgery was increasingly utilized over the study period in urgent (38% in 2011 to 71% in 2018; p < 0.0001) and emergent (0% in 2005 to 42% in 2018; p < 0.0001) groups. Compared to minimally invasive surgery, open surgery was associated with a higher risk of surgical, septic, and overall complications, and prolonged hospitalization. LIMITATIONS: This study was limited by its retrospective nature of the analysis. CONCLUSION: Based on a nationwide analysis from the United States, minimally invasive surgery has been increasingly and safely implemented for emergent and urgent indications for ulcerative colitis. Although the sum of emergent and urgent cases remained the same over the study period, emergency cases decreased significantly over the study period, which may be related to improved medical treatment options and a collaborative, specialized team approach. See Video Abstract at http://links.lww.com/DCR/B847 . CIRUGA DE URGENCIA Y EMERGENCIA PARA LA COLITIS ULCEROSA EN LOS ESTADOS UNIDOS EN LA ERA MNIMAMENTE INVASIVA Y DE TERAPIA BIOLGICA: ANTECEDENTES:Si bien se ha establecido la adopción generalizada de la cirugía mínimamente invasiva en el tratamiento electivo de la colitis ulcerosa, se sabe poco sobre su utilización en situaciones de emergencia.OBJETIVO:Evaluar las tasas de cirugía de urgencia a lo largo del tiempo en la era de las terapias biológicas emergentes y destacar la práctica actual en los Estados Unidos con respecto a la utilización de la cirugía mínimamente invasiva para las indicaciones de urgencia y emergencia de la colitis ulcerosa.DISEÑO:Análisis retrospectivo.AJUSTES:Base de datos del Programa Nacional de Mejoramiento de la Calidad del Colegio Americano de Cirujanos.PACIENTES:Todos los pacientes adultos que se sometieron a colectomía de emergencia o urgencia por colitis ulcerosa.MEDIDAS DE RESULTADO:Se evaluaron las tasas de operaciones de emergencia a lo largo del tiempo y las tendencias de utilización de la cirugía mínimamente invasiva en entornos de urgencia y emergencia. Se compararon las tasas de complicaciones generales, quirúrgicas y médicas de 30 días no ajustadas y ajustadas entre la cirugía abierta y la mínimamente invasiva.RESULTADOS:Se identificaron un total de 2.219 pacientes. De ellos, 1.515 pacientes (68,3%) fueron intervenidos de urgencia y 704 (31,7%) de emergencia. Los casos emergentes disminuyeron con el tiempo (21% en 2006 a 8% en 2018; p <0,0001). Sin embargo, la tasa de cirugías urgentes no ha cambiado significativamente (42% en 2011 a 46% en 2018, p = 0,44). Se ofreció cirugía mínimamente invasiva al 70% de los pacientes del grupo urgente (1.058 / 1.515) y al 22,6% de las emergencias (159/704). En general, la cirugía mínimamente invasiva se utilizó cada vez más durante el período de estudio en grupos urgentes (38% en 2011 a 71% en 2018; p <0,0001) y emergentes (0% en 2005 a 42% en 2018; p <0,0001). En comparación con la cirugía mínimamente invasiva, la cirugía abierta se asoció con un mayor riesgo de complicaciones generales, quirúrgicas, sépticas y hospitalización prolongada.LIMITACIONES:Carácter retrospectivo del análisis.CONCLUSIÓNES:Basado en un análisis nacional de los Estados Unidos, la cirugía mínimamente invasiva se ha implementado de manera creciente y segura para las indicaciones emergentes y urgentes de la colitis ulcerosa. Si bien la suma de casos emergentes y urgentes permaneció igual durante el período de estudio, los casos de emergencia disminuyeron significativamente, lo que puede estar relacionado con mejores opciones de tratamiento médico y un enfoque de equipo colaborativo y especializado. Consulte Video Resumen en http://links.lww.com/DCR/B847 . (Traducción-Dr. Felipe Bellolio ).

Survival impact of adjuvant chemotherapy in patients with stage IIA colon cancer: Analysis of the National Cancer Database.

Utility of adjuvant chemotherapy for stage II cancer remains a matter of debate. Clinical guidelines suggest adjuvant chemotherapy for stage II tumors with high-risk features, in particular T4 tumors. However, limited consensus exists regarding the importance of other high-risk features (lymphovascular or perineural invasion, microsatellite instability). Our study aimed to investigate the impact of adjuvant chemotherapy for stage IIA (T3N0) colon cancer patients. Patients who underwent colectomy for stage IIA colon adenocarcinoma (2010-2015) were identified in the National Cancer Database (NCDB) and divided in two groups based on receipt of adjuvant chemotherapy vs observation. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox proportional hazards regression analyses were performed to compare overall survival between the two groups. Subgroup analysis of patients with specific high-risk features LVI, PNI and MSI was performed. Among 46 688 surgical patients with stage IIA colon adenocarcinoma 5937 (12.7%) received adjuvant chemotherapy, while 40 751 (87.3%) were observed. Five-year IPTW-adjusted survival was higher in the adjuvant chemotherapy group (79.7% [95% CI 79.1, 80.2]) compared to the observation group (70.3% [95% CI 69.7, 70.9]). Patients with high-risk pathological features showed an estimated 5-year survival benefit of 11.3% (78.2% [95% CI 77.4, 79.1] vs 66.9% [95% CI 65.9, 67.8]) when treated with adjuvant chemotherapy. This NCDB analysis revealed a survival benefit for patients with stage IIA colon adenocarcinoma and high-risk features that were treated with adjuvant chemotherapy.

Rescuing the Clinical Breast Examination: Advances in Classifying Technique and Assessing Physician Competency.

OBJECTIVE: Develop new performance evaluation standards for the clinical breast examination (CBE). SUMMARY BACKGROUND DATA: There are several, technical aspects of a proper CBE. Our recent work discovered a significant, linear relationship between palpation force and CBE accuracy. This article investigates the relationship between other technical aspects of the CBE and accuracy. METHODS: This performance assessment study involved data collection from physicians (n = 553) attending 3 different clinical meetings between 2013 and 2014: American Society of Breast Surgeons, American Academy of Family Physicians, and American College of Obstetricians and Gynecologists. Four, previously validated, sensor-enabled breast models were used for clinical skills assessment. Models A and B had solitary, superficial, 2 cm and 1 cm soft masses, respectively. Models C and D had solitary, deep, 2 cm hard and moderately firm masses, respectively. Finger movements (search technique) from 1137 CBE video recordings were independently classified by 2 observers. Final classifications were compared with CBE accuracy. RESULTS: Accuracy rates were model A = 99.6%, model B = 89.7%, model C = 75%, and model D = 60%. Final classification categories for search technique included rubbing movement, vertical movement, piano fingers, and other. Interrater reliability was (k = 0.79). Rubbing movement was 4 times more likely to yield an accurate assessment (odds ratio 3.81, P < 0.001) compared with vertical movement and piano fingers. Piano fingers had the highest failure rate (36.5%). Regression analysis of search pattern, search technique, palpation force, examination time, and 6 demographic variables, revealed that search technique independently and significantly affected CBE accuracy (P < 0.001). CONCLUSIONS: Our results support measurement and classification of CBE techniques and provide the foundation for a new paradigm in teaching and assessing hands-on clinical skills. The newly described piano fingers palpation technique was noted to have unusually high failure rates. Medical educators should be aware of the potential differences in effectiveness for various CBE techniques.

Do resident's leadership skills relate to ratings of technical skill?

BACKGROUND: This study sought to compare general surgery research residents' survey information regarding self-efficacy ratings to their observed performance during a simulated small bowel repair. Their observed performance ratings were based on their leadership skills in directing their assistant. METHODS: Participants were given 15 min to perform a bowel repair using bovine intestines with standardized injuries. Operative assistants were assigned to help assist with the repair. Before the procedure, participants were asked to rate their expected skills decay, task difficulty, and confidence in addressing the small bowel injury. Interactions were coded to identify the number of instructions given by the participants to the assistant during the repair. Statistical analyses assessed the relationship between the number of directional instructions and participants' perceptions self-efficacy measures. Directional instructions were defined as any dialog by the participant who guided the assistant to perform an action. RESULTS: Thirty-six residents (58.3% female) participated in the study. Participants who rated lower levels of decay in their intraoperative decision-making and small bowel repair skills were noted to use their assistant more by giving more instructions. Similarly, a higher number of instructions correlated with lower perceived difficulty in selecting the correct suture, suture pattern, and completing the entire surgical task. CONCLUSIONS: General surgery research residents' intraoperative leadership skills showed significant correlations to their perceptions of skill decay and task difficulty during a bowel repair. Evaluating resident's directional instructions may provide an additional individualized intraoperative assessment metric. Further evaluation relating to operative performance outcomes is warranted.

Resident performance in complex simulated urinary catheter scenarios.

BACKGROUND: Urinary catheter insertion is a common procedure performed in hospitals. Improper catheterization can lead to unnecessary catheter-associated urinary tract infections and urethral trauma, increasing patient morbidity. To prevent such complications, guidelines were created on how to insert and troubleshoot urinary catheters. As nurses have an increasing responsibility for catheter placement, resident responsibility has shifted to more complex scenarios. This study examines the clinical decision-making skills of surgical residents during simulated urinary catheter scenarios. We hypothesize that during urinary catheterization, residents will make inconsistent decisions relating to catheter choices and clinical presentations. METHODS: Forty-five general surgery residents (postgraduate year 2-4) in Midwest training programs were presented with three of four urinary catheter scenarios of varying difficulty. Residents were allowed 15 min to complete the scenarios with five different urinary catheter choices. A chi-square test was performed to examine the relation between initial and subsequent catheter choices and to evaluate for consistency of decision-making for each scenario. RESULTS: Eighty-two percent of residents performed scenario A; 49% performed scenario B; 64% performed scenario C, and 82% performed scenario D. For initial attempt for scenario A-C, the 16 French Foley catheter was the most common choice (38%, 54%, 50%, P's < 0.001), whereas for scenario D, the 16 French Coude was the most common choice (37%, P < 0.01). Residents were most likely to be successful in achieving urine output in the initial catheterization attempt (P < 0.001). Chi-square analyses showed no relationship between residents' first and subsequent catheter choices for each scenario (P's > 0.05). CONCLUSIONS: Evaluation of clinical decision-making shows that initial catheter choice may have been deliberate based on patient background, as evidenced by the most popular choice in scenario D. Analyses of subsequent choices in each of the catheterization models reveal inconsistency. These findings suggest a possible lack of competence or training in clinical decision-making with regard to urinary catheter choices in residents.

Residents' perception of skill decay during dedicated research time.

BACKGROUND: Surgery residents may take years away from clinical responsibilities for dedicated research time. As part of a longitudinal project, the study aim was to investigate residents' perceptions of clinical skill reduction during dedicated research time. Our hypothesis was that residents would perceive a greater potential reduction in skill during research time for procedures they were less confident in performing. MATERIALS AND METHODS: Surgical residents engaged in dedicated research training at multiple training programs participated in four simulated procedures: urinary catheterization, subclavian central line, bowel anastomosis, and laparoscopic ventral hernia (LVH) repair. Using preprocedure and postprocedure surveys, participants rated procedures for confidence and difficulty. Residents also indicated the perceived level of skills reduction for the four procedures as a result of time in the laboratory. RESULTS: Thirty-eight residents (55% female) completed the four clinical simulators. Participants had between 0-36 mo in a laboratory (M = 9.29 mo, standard deviation = 9.38). Preprocedure surveys noted lower confidence and higher perceived difficulty for performing the LVH repair followed by bowel anastomosis, central line insertion, and urinary catheterization (P < 0.05). Residents perceived the greatest reduction in bowel anastomosis and LVH repair skills compared with urinary catheterization and subclavian central line insertion (P < 0.001). Postprocedure surveys showed significant effects of the simulation scenarios on resident perception for urinary catheterization (P < 0.05) and LVH repair (P < 0.05). CONCLUSIONS: Residents in this study expected greater skills decay for the procedures they had lower confidence performing and greater perceived difficulty. In addition, carefully adapted simulation scenarios had a significant effect on resident perception and may provide a mechanism for maintaining skills and keeping confidence grounded in experience.

Operative skill: quantifying surgeon's response to tissue properties.

BACKGROUND: The aim of this study was to investigate how tissue characteristics influence psychomotor planning and performance during a suturing task. Our hypothesis was that participants would alter their technique based on tissue type with each subsequent stitch placed while suturing. MATERIALS AND METHODS: Surgical attendings (n = 6), residents (n = 4), and medical students (n = 5) performed three interrupted sutures on different simulated materials as follows: foam (dense connective tissue), rubber balloons (artery), and tissue paper (friable tissue). An optical motion tracking system captured performance data from participants' bilateral hand movements. Path length and suture time were segmented by each individual stitch placed to investigate changes to psychomotor performance with subsequent stitch placements. Repeated measures analysis of variance was used to evaluate for main effects of stitch order on path length and suture time and interactions between stitch order, material, and experience. RESULTS: When participants sutured the tissue paper, they changed their procedure time (F(4,44) = 5.14, P = 0.017) and path length (F(4,44) = 4.64, P = 0.003) in a linear fashion with the first stitch on the tissue paper having the longest procedure time and path length. Participants did not change their path lengths and procedure times when placing subsequent stitches in the foam (P = 0.910) and balloon materials (P = 0.769). CONCLUSIONS: This study demonstrates quantifiable real-time adaptation by participants to material characteristics during a suturing task. Participants improved their motion-based performance with each subsequent stitch placement indicating changes in psychomotor planning or performance. This adaptation did not occur with the less difficult tasks. Motion capture technology is a promising method for investigating surgical performance and how surgeons adapt to operative complexity.

Assessing the stops framework for coping with intraoperative errors: Evidence of efficacy, hints of hubris, and a bridge to abridging burnout.

BACKGROUND: Answering calls in the literature, we developed and introduced an evidence-based tool for surgeons facing errors in the operating room: the STOPS framework (stop, talk to you team, obtain help, plan, succeed). The purpose of this research was to assess the impact of presenting this psychological tool on resident coping in the operating room and the related outcome of burnout while examining sex differences. METHODS: In a natural experiment, general surgery residents were invited to attend 2 separate educational conferences regarding coping with errors in the operating room. Three months later, all residents were asked to fill out a survey assessing their coping in the operating room, level of burnout, and demographics. We assessed the impact of the educational intervention by comparing those who attended the coping conferences with those who did not attend. RESULTS: Thirty-five residents responded to the survey (65% response rate, 54% female respondents, 49% junior residents). Our hypothesized moderated mediation model was supported. Sex was found to moderate the impact of the STOPS framework-female residents who attended the coping educational conference reported higher coping self-efficacy, whereas attendance had no statistically significant impact on male levels of coping self-efficacy. In turn, higher coping self-efficacy was associated with lower levels of burnout. CONCLUSION: Our results suggest that there is evidence of efficacy in this instruction-female residents presented this material report higher levels of coping in the operating room compared to those who did not receive the framework. Further, increase in coping ability was associated with reduced levels of burnout for both genders.

Effect of previous abdominal surgery on robotic-assisted rectal cancer surgery.

BACKGROUND: The effect of previous abdominal surgery (PAS) in laparoscopic surgery is well known and significantly adds to longer hospital length of stay (LOS), postoperative ileus, and inadvertent enterotomies. However, little evidence exists in patients with PAS undergoing robotic-assisted (RA) rectal surgery. METHODS: All patients undergoing RA surgery for rectal cancer were reviewed. Patients with PAS were divided into minor and major PAS groups, defined as surgery involving >1 quadrant. The primary outcome was the risk of conversion to open surgery. RESULTS: A total of 750 patients were included, 531 in the no-PAS (NPAS) group, 31 in the major PAS group, and 188 in the minor PAS group. Patients in the major PAS group had significantly longer hospital LOS (P < .001) and lower adherence to enhanced recovery pathways (ERPs; P = .004). The conversion rates to open surgery were similar: 3.4% in the NPAS group, 5.9% in the minor PAS group, and 9.7% in the major PAS group (P = .113). Estimated blood loss (EBL; P = .961), operative times (OTs; P = .062), complication rates (P = .162), 30-day readmission (P = .691), and 30-day mortality (P = .494) were similar. Of note, 53 patients underwent lysis of adhesions (LOA). On multivariate analysis, EBL >500 mL and LOA significantly influenced conversion to open surgery. EBL >500 mL, age >65 years, conversion to open surgery, and prolonged OT were risk factors for prolonged LOS, whereas adherence to ERPs was a protector. CONCLUSION: PAS did not seem to affect the outcomes in RA rectal surgery. Given this finding, the robotic approach may ultimately provide patients with PAS with similar risk to patients without PAS.

Evolution of laparoscopic ileal pouch-anal anastomosis: impact of enhanced recovery program, medication changes, and staged approaches on outcomes.

BACKGROUND: Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage. METHODS: Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes. RESULTS: The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P < .001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P < .001) or immunomodulators (0% vs 31%, respectively; P < .001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5 ± 78.4 vs 233.8 ± 81.6, respectively; P < .001) and length of stay (LOS; 5.4 ± 3.1 vs 4.2 ± 1.6 days, respectively; P < .001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P = .04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P = .02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P = .01), whereas 3-staged IPAA reduced complications (OR, 0.3; P = .03). ERP was identified as a factor that predicted shorter stays. CONCLUSION: Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications.

Scrubbing With Aristotle: Cultivating Surgical Wisdom through Inflection Points.

Surgical educators and researchers have well-considered a breadth of topics related to surgery. However, there is one concept that is notably absent in this corpus: surgical wisdom. In this perspective, we draw on work from Aristotle and psychology research to introduce the concept of phronesis, which we believe is useful for understanding surgical wisdom. We further illustrate how this concept can be a useful tool for surgical educators through the discussion of four distinct functions of phronesis, and illustrating the ability of these functions to help learners cultivate knowledge at important decision points, or inflection points, in surgical training and a surgical career.

Implementation of a Brief Evidence-Based Intraoperative Coping Curriculum.

BACKGROUND AND RATIONALE: Recent research has called for further resident training in coping with errors and adverse events in the operating room. To the best of our knowledge, there currently exists no evidence-based curriculum or training on this topic. MATERIALS AND METHODS: Synthesizing three prior studies on how experienced surgeons react to errors and adverse events, we developed the STOPS framework for handling surgical errors and adverse events (Stop, Talk to your team, Obtain help, Plan, Succeed). This material was presented to residents in two teaching sessions. RESULTS AND CONCLUSION: In this paper, we describe the presentation of, and the uniformly positive resident reaction to, the STOPS framework: an empirically based psychological tool for surgeons who experience operative errors or adverse events.

The good, the bad, and the ugly: Operative staff perspectives of surgeon coping with intraoperative errors.

BACKGROUND: Intraoperative errors are inevitable, and how surgeons respond impacts patient outcomes. Although previous research has queried surgeons on their responses to errors, no research to our knowledge has considered how surgeons respond to operative errors from a contemporary first-hand source: the operating room staff. This study evaluated how surgeons react to intraoperative errors and the effectiveness of employed strategies as witnessed by operating room staff. METHODS: A survey was distributed to operating room staff at 4 academic hospitals. Items included multiple-choice and open-ended questions assessing surgeon behaviors observed after intraoperative error. Participants reported the perceived effectiveness of the surgeon's actions. RESULTS: Of 294 respondents, 234 (79.6%) reported being in the operating room when an error or adverse event occurred. Strategies positively associated with effective surgeon coping included the surgeon telling the team about the event and announcing a plan. Themes emerged regarding the importance of the surgeon remaining calm, communicating, and not blaming others for the error. Evidence of poor coping also emerged: "Yelling, feet stomping and throwing objects onto the field. [The surgeon] cannot articulate needs well because of anger." CONCLUSION: These data from operating room staff corroborates previous research presenting a framework for effective coping while shedding light on new, often poor, behaviors that have not emerged in prior research. Surgical trainees will benefit from the now-enhanced empirical foundation on which coping curricula and interventions can be built.

Revealing hidden experiences: Gendered microaggressions and surgical faculty burnout.

BACKGROUND: Studies report higher burnout in women faculty surgeons compared to men. However, few studies have examined underlying mechanisms for these gendered differences. Gendered differences in microaggression experiences may explain part of the relationship between gender and burnout. We aimed to investigate the relationship between gender, gendered microaggressions, and burnout and test the hypothesis that microaggressions contribute to the relationship between gender and burnout. METHODS: In this 2021 study, a survey was distributed to surgical faculty at 7 institutions. Variables included gender identity, race, average hours worked recently, the Oldenburg Burnout Inventory, and a modified Racial and Ethnic Microaggressions Scale to assess gendered microaggressions. To assess the relationship between surgical faculty gender and burnout, and if this relationship could be explained by microaggressions, a mediation model was tested. RESULTS: A total of 109 participants (40% female) completed the survey and were included in analysis. The hypothesized indirect effect of gender on burnout (M = 2.70/5, SD = 0.81), through gender-based microaggressions (M = 1.7/5, SD = 1.9), was significant, B = -0.25, SE B = 0.09, confidence interval (-0.44 to -0.09): women surgeons reported higher levels of gendered microaggressions, which predicted higher levels of burnout. The overall model was significant (R2 = .16, F[6,102] = 3.33, P < .01). Race, specialty, hours worked, and years of experience were all not significant in the model. CONCLUSION: Gendered microaggressions mediate the relationship between gender and burnout, providing a potential mechanism for the higher rates of burnout in women surgeons evident in prior research. These multi-institutional data provide a focus for targeted initiatives that could decrease both burnout rates and the impact of gender bias on surgical faculty.