A randomized, double-blinded, placebo-controlled trial of the effects of infusing local analgesia on post-operative pain during laparoscopic inguinal hernia repair.

PURPOSE: While it is widely accepted that laparoscopic total extraperitoneal (TEP) inguinal herniorrhaphy has decreased post-operative pain, there are conflicting data as to whether instillation of local anesthetic into the preperitoneal space improves post-operative pain in these patients. We designed a prospective study to evaluate this. Secondary outcomes include time spent in the PACU, need for narcotic pain medication, and total amount of narcotics required postoperatively. METHODS: Prospective, randomized, double-blind, placebo-controlled study which enrolled 70 patients with unilateral non-recurrent inguinal hernia from 09/2013 to 03/2019 and included immediate and 2-week post-operative follow-up. All patients received unilateral laparoscopic TEP inguinal hernia repair with control patients receiving 10 ml of 0.9% saline instilled into preperitoneal space while treatment group received 10-ml 0.5% bupivacaine without epinephrine. RESULTS: A total of 70 patients [67 (96%) men and 3 women; mean age (SD), 57 years (13.8)] were enrolled, 35 randomized into each group. Demographics between the two groups were similar. No differences were found in post-operative pain between the control and test groups at 1 h [mean (SD) of 3.15(2.5) vs 3.21(2.9); P = 0.92], 2 h [3.39 (1.55) vs 2.74 (1.85) P = 0.18], or 1 day [4.79 (2.19) vs 4.39 (2.37); P = 0.13] postoperatively. Likewise, no significant differences were observed in usage of narcotic pain medication postoperatively, as 17 control patients (50%) and 16 (46%) study patients required narcotics within 2 h of surgery (P = 0.72). CONCLUSION: Instilling local anesthetic into the preperitoneal space during laparoscopic TEP inguinal hernia repair did not result in statistically significant difference in post-operative pain (Rade et al. in NESS Annual Meeting, 2021). Trial registry ClinicalTrials.gov Identifier: NCT02055053.

What are essential laparoscopic skills these days? Results of the SAGES Fundamentals of Laparoscopic Surgery (FLS) Committee technical skills survey.

INTRODUCTION: The Fundamentals of Laparoscopic Surgery (FLS) program tests basic knowledge and skills required to perform laparoscopic surgery. Educational experiences in laparoscopic training and development of associated competencies have evolved since FLS inception, making it important to review the definition of fundamental laparoscopic skills. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) assigned an FLS Technical Skills Working Group to characterize technical skills used in basic laparoscopic surgery in current practice contexts and their possible application to future FLS tests. METHODS: A group of subject matter experts defined an inventory of 65 laparoscopic skills using a Nominal Group Technique. From these, a survey was developed rating these items for importance, frequency of use, and priority for testing for FLS certification. This survey was distributed to SAGES members, recent recipients of FLS certification, and members of the Association of Program Directors in Surgery (APDS). Results were collected using a secure web-based survey platform. RESULTS: Complete data were available for 1742 surveys. Of these, 1143 comprised results for post-residency participants who performed advanced procedures. Seventeen competencies were identified for FLS testing prioritization by determining the proportion of respondents who identified them of highest priority, at median (50th percentile) of the maximum survey scale rating. These included basic peritoneal access, laparoscope and instrument use, tissue manipulation, and specific problem management skills. Sixteen could be used to show appropriateness of the domain construct by confirmatory factor analysis. Of these 8 could be characterized as manipulative tasks. Of these 5 mapped to current FLS tasks. CONCLUSIONS: This survey-identified competencies, some of which are currently assessed in FLS, with a high level of priority for testing. Further work is needed to determine if this should prompt consideration of changes or additions to the FLS technical skills test component.

Evidence-based Guidelines on the Use of Virtual Surgical Education Pertaining to the Domains of Cognition and Curriculum, Psychomotor Skills Training, and Faculty Development and Mentorship.

OBJECTIVE: To identify, categorize, and evaluate the quality of literature, and to provide evidence-based guidelines on virtual surgical education within the cognitive and curricula, psychomotor, and faculty development and mentorship domains. SUMMARY OF BACKGROUND DATA: During the coronavirus disease 2019 pandemic, utilizing virtual learning modalities is expanding rapidly. Although the innovative methods must be considered to bridge the surgical education gap, a framework is needed to avoid expansion of virtual education without proper supporting evidence in some areas. METHODS: The Association for Surgical Education formed an ad-hoc research group to evaluate the quality and methodology of the current literature on virtual education and to build evidence-based guidelines by utilizing the SiGN methodology. We identified patient/problem-intervention-comparison-outcome-style questions, conducted systematic literature reviews using PubMed, EMBASE, and Education Resources information Center databases. Then we formulated evidence-based recommendations, assessed the quality of evidence using Grading of Recommendations, Assessment, Development, and Evaluation, Newcastle-Ottawa Scale for Education, and Kirkpatrick ratings, and conducted Delphi consensus to validate the recommendations. RESULTS: Eleven patient/problem-intervention-comparison-outcome-style questions were designed by the expert committees. After screening 4723 articles by the review committee, 241 articles met inclusion criteria for full article reviews, and 166 studies were included and categorized into 3 domains: cognition and curricula (n = 92), psychomotor, (n = 119), and faculty development and mentorship (n = 119). Sixteen evidence-based recommendations were formulated and validated by an external expert panel. CONCLUSION: The evidence-based guidelines developed using SiGN methodology, provide a set of recommendations for surgical training societies, training programs, and educators on utilizing virtual surgical education and highlights the area of needs for further investigation.

Evaluation of a stand-alone robotic camera holding system: technology that improves laparoscopy.

INTRODUCTION: In order to perform laparoscopic procedures, a surgeon requires an assistant to hold the camera. Problems with this approach include table crowding leading to poor ergonomics, and miscommunication leading to poor images. AutoLap is a novel FDA-approved camera navigation system. We present our experience with this device and compare it to human camera holders. MATERIALS AND METHODS: The study design included an initial training period followed by a non-randomized allocation between robotic and human camera holder cohort. Data included set up time, ergonomics and usability (via nurse, surgeon and camera holder questionnaire) and image stability recorded via the Inertial Measurement Unit (IMU), describing linear acceleration (in unit gravity [g]) and horizontal acceleration (Angular Velocity in rad/s). RESULTS: Twenty-six patients were equally divided between human and robotic camera holders. Image stability were significantly better for the robotic camera holder. Median angular velocity was 0.029 and 0.005 rad/s for human and the AutoLap system, respectively (p-value <.001). Linear acceleration was 0.011 and 0.007 [g] (p-value .015). Positive feedback for the robotic system included greater surgeon comfort (92%) and improved nurse - surgeon interaction (100%). CONCLUSIONS: The AutoLap system provides improved image stability, team-work, and ergonomic comfort for the surgical team with minimum set-up time.

What are the skills that represent expert-level laparoscopic suturing? A Delphi Study.

BACKGROUND: As the field of laparoscopic surgery grows, the need for a valid assessment of laparoscopic surgical skills becomes apparent. The objective of this study was to identify laparoscopic suturing skills reflective of performing at an expert level. METHODS: A Delphi Study was conducted with expert laparoscopic surgeons. Tasks were considered to meet criteria for consensus after 80% of survey participants answered "strongly agree." Results of the previous round of surveys were shared with participants at the start of the next round. The predefined endpoint for the Delphi was set as maximum of three rounds, reaching 80% consensus on each skill, or if > 50% of initial respondents fail to return for subsequent surveys. RESULTS: After three rounds of surveys completed by 13 advanced laparoscopic surgeons, 8 observed skills met consensus (> 80% selected "strongly agree"): forehand suturing, continuous suturing, avoiding tissue trauma, achieving a technically acceptable final product (tight closure), tying a secure knot at the end of suturing, maintaining/checking for appropriate tightness of running suture, accurate depth perception, and loading the needle in < 3 attempts. Skills that approached consensus (with > 50% ranking them as "strongly agree") included correct penetration of target tissue, ability to create a surgeon's knot, awareness of needle tip position, confined space suturing, following the curve of the needle, smooth movements of instruments, loading the needle correctly, adjusting for tissue thickness, and bimanual dexterity. CONCLUSIONS: Using Delphi methodology, we identified the skills that are representative of expert laparoscopic suturing. This information can be used to create an assessment tool for this domain. Validation of such a tool will help advance the surgical field towards true competency-based assessment of expertise.

Resident participation in laparoscopic Roux-en-Y gastric bypass: a comparison of outcomes from the ACS-NSQIP database.

BACKGROUND: As clinical outcome data are increasingly tied to hospital reimbursement, balancing quality care with training of surgical residents has become critical. We used the ACS-NSQIP database to determine impact of resident participation in laparoscopic gastric bypass on 30-day morbidity and mortality. METHODS: We queried the ACS-NSQIP database from 1/2005 to 12/2012 for laparoscopic gastric bypass, dividing cases between those with or without resident involvement. Univariate and multivariate analyses of intraoperative and postoperative outcomes were assessed. A sub-analysis was performed to address whether different resident training levels affected outcomes. RESULTS: A total of 43,477 laparoscopic gastric bypass cases were available for analysis; 22,189 had resident involvement (resident = R), and 21,288 did not (no resident = NR). Preoperative characteristics were similar between groups. On multivariate analysis, procedures with resident assistance had increased risk of the following complications: superficial site infection (R = 2.1 vs. 1.5 %, p < 0.001), renal failure (R = 0.4 vs. NR = 0.3 %, p = 0.002), urinary tract infection (R = 1.1 vs. 0.9 %, p = 0.027), and sepsis (R = 0.8 vs. NR = 0.6 %, p = 0.019). Increased operative time in the resident group (29 min, p < 0.0001) demonstrated direct linear association with resident trainee level. There was no statistical difference in the incidences of the following: pulmonary embolism, deep venous thrombosis, deep surgical site infection, organ space infection, pneumonia, unplanned intubation, mechanical ventilation >48 h, septic shock, cardiac arrest, return to the operating room, or mortality. CONCLUSION: Resident participation in laparoscopic gastric bypass was associated with statistically significant, but clinically insignificant increase in incidence of superficial site infection, renal failure, readmission rate, and length of stay. Therefore, although resident participation in laparoscopic gastric bypass is associated with significantly increased operative time, it does not lead to increased mortality and has no clinically significant effect on morbidity.

Evaluation of advanced laparoscopic skills tasks for validity evidence.

BACKGROUND: Since fundamentals of laparoscopic surgery (FLS) represents a minimum proficiency standard for laparoscopic surgery, more advanced proficiency standards are required to address the needs of current surgical training. We wanted to evaluate the acceptance and discriminative ability of a novel set of skills building on the FLS model that could represent a more advanced proficiency standard-advanced laparoscopic surgery (ALS). METHODS: Qualitative and quantitative analyses were employed. Quantitative analysis involved comparison of expert (PGY 5+), intermediate (PGY 3-4) and novice (PGY 1-2) surgeons on FLS and ALS tasks. Composite scores included time and errors. Standard FLS errors were added to task time to create the composite score. Qualitative analysis involved thematic review of open-ended questions provided to experts participating in the study. RESULTS: Out of 48 participants, there were 15 (31 %) attendings, 3 (6 %) fellows and 30 (63 %) residents. By specialty, 54 % were general/MIS/bariatric/colorectal (GMBC) and 46 % were other (urology and gynecology). There was no difference between experience level and performance on FLS and ALS tasks for the entire cohort. However, looking at the GMBC subgroup, experts performed better than novices (p = 0.012) and intermediates performed better than novices (p = 0.057) on ALS tasks. There was no difference for the same group in FLS performance. Also, GMBC subgroup performed significantly better on FLS (p = 0.0035) and ALS (p = 0.0027) than the other subgroup. Thematic analysis revealed that the majority of experts felt that ALS was more realistic, challenging and clinically relevant for specific situations compared to FLS. CONCLUSION: For GMBC surgeons, we were able to show evidence of validity for a series of advanced laparoscopic tasks and their relationship to surgeon skill level. This study may represent the first step in the development of an advanced laparoscopic skills curriculum. Given the high degree of specialization in surgery, different advanced skills curricula will need to be developed for each specialty.

Establishing technical performance norms for general surgery residents.

BACKGROUND: Surgery residents are required to achieve performance milestones to advance in their residency. Level-specific, technical performance norms that could be used as milestones, however, do not currently exist. Our aim was to develop level-specific, technical performance norms for general surgery residents on select simulated tasks across multiple institutions. STUDY DESIGN: An IRB-approved, prospective, multi-institutional collaborative study with voluntary participation of residents was undertaken at the start of the 2011-2012 academic year. General surgery residents (PGY I-V) from seven institutions were tested on three laparoscopic and five open simulated surgical tasks, and their performance was assessed based on task time and errors. Means and standard deviations of performance for each resident level were calculated and compared. Residents with performance 1 standard deviation below the mean were considered outliers. RESULTS: A total of 147 residents were evaluated. Mean resident age was 28 ± 3 years; 42 % were female; and they had attended 74 different medical schools. Senior residents (PGY III-V) had more clinical and simulator experience than junior residents (PGY I-II) (p < 0.001). Resident performance scores progressively increased in all tasks reaching a plateau at a lower PGY level for open tasks. Depending on the task, 0-18 % of residents were outliers. When surveyed, 66 % of residents agreed that national performance norms for residents should exist. CONCLUSIONS: Performance norms were established for select tasks in a representative sample of US surgery residents. Such performance norms allow a more informed assessment of resident skill through comparison to national data and enable the identification of outliers who may benefit from additional training.

Can Surgeons Reliably Identify Non-cirrhotic Liver Disease During Laparoscopic Bariatric Surgery?

INTRODUCTION: Identification of liver disease during bariatric operations is an important task given the patients risk for occult fatty liver disease. Surgeon's accuracy of assessing for liver disease during an operation is poorly understood. The objective was to measure surgeons' performance on intra-operative visual assessment of the liver in a simulated environment. METHODS: Liver images from 100 patients who underwent laparoscopic bariatric surgery and pre-operative ultrasound elastography between July 2020 and July 2021 were retrospectively evaluated. The perception of 15 surgeons regarding the degree of hepatic steatosis and fibrosis was collected in a simulated clinical environment by survey and compared to results determined by ultrasonographic exam. RESULTS: The surgeons' ability to correctly identify the class of steatosis and fibrosis was poor (accuracy 61% and 59%, respectively) with a very weak correlation between the surgeon's predicted class and its true class (r = 0.17 and r = 0.12, respectively). When liver disease was present, surgeons completely missed its presence in 26% and 51% of steatosis and fibrosis, respectively. Digital image processing demonstrated that surgeons subjectively classified steatosis based on the "yellowness" of the liver and fibrosis based on texture of the liver, despite neither correlating with the true degree of liver disease. CONCLUSION: Laparoscopic visual assessment of the liver surface for identification of non-cirrhotic liver disease was found to be an inaccurate method during laparoscopic bariatric surgery. While validation studies are needed, the results suggest the clinical need for alternative approaches.

Needs Assessment for a Resuscitative Thoracotomy Curriculum for General Surgery Residents in the Northeast Region.

INTRODUCTION: Resuscitative thoracotomy (RT) is a high-acuity low occurrence (HALO) procedure with which general surgical resident (GSR) experience and confidence are unknown. We sought to identify and describe this educational gap by conducting a targeted needs assessment for an RT curriculum for GSRs. METHODS: An online regional needs assessment survey was conducted for an RT curriculum for GSRs. The survey was developed by a group of trauma stakeholders and revised after being piloted on a small, representative group of GSRs. We surveyed GSRs in the Northeast region regarding their experience and confidence with RT; interest in an RT curriculum; and content, format, and scope for an RT curriculum. RESULTS: The survey response rate was 43%, reflecting the viewpoints of GSRs at 8 major training centers across the Northeast. Only 13% of respondents were interested in pursuing a career in Trauma and Critical Care despite 97% of them training at a Level I Trauma Center. Twenty-nine percent and 33% of GSRs had ever assisted with or performed RT, respectively. Twenty-one percent of GSRs reported feeling confident performing RT. Most respondents (98%) agreed or strongly agreed that an RT curriculum would add value to their general surgery education. The most positively rated content topics were resuscitative maneuvers (100% positive responses [PR]), when to cease resuscitative efforts (100% PR), and morbidity and mortality associated with RT (98% PR). The most highly rated learning methods were individual RT simulation time (97% PR) and a tour of the trauma bay equipment (97% PR). CONCLUSIONS: This needs assessment demonstrates a lack of experience and confidence with RT, a strong learner interest in an RT curriculum, and a desire for experiential learning methods. Learning objectives are defined herein, and the next steps involve developing educational materials for an RT curriculum for GSRs.

Update on the Financial Well-Being of Surgical Residents in New England.

BACKGROUND: Poor personal financial health has been linked to key components of health including burnout, substance abuse, and worsening personal relationships. Understanding the state of resident financial health is key to improving their overall well-being. STUDY DESIGN: A secondary analysis of a survey of New England general surgery residents was performed to understand their financial well-being. Questions from the National Financial Capability Study were used to compare to an age-matched and regionally matched cohort. RESULTS: Overall, 44% (250 of 570) of surveyed residents responded. Residents more frequently reported spending less than their income each year compared to the control cohort (54% vs 34%, p < 0.01). However, 17% (39 of 234) of residents reported spending more than their income each year. A total of 65% of residents (152 of 234), found it "not at all difficult" to pay monthly bills vs 17% (76 of 445) of the control cohort (p < 0.01). However, 32% (75 of 234) of residents reported it was "somewhat" or "very" difficult to pay monthly bills. Residents more frequently reported they "certainly" or "probably" could "come up with" $2,000 in a month compared to the control cohort (85% vs 62% p < 0.01), but 16% (37 of 234) of residents reported they could not. In this survey, 21% (50 of 234) of residents reported having a personal life insurance policy, 25% (59 of 234) had disability insurance, 6% (15 of 234) had a will, and 27% (63 of 234) had >$300,000 worth of student loans. CONCLUSIONS: Surgical residents have better financial well-being than an age-matched and regionally matched cohort, but there is still a large proportion who suffer from financial difficulties.

Update on the Personal and Professional Well-Being of Surgical Residents in New England.

BACKGROUND: Surgical culture has shifted to recognize the importance of resident well-being. This is the first study to longitudinally track regional surgical resident well-being over 5 years. STUDY DESIGN: An anonymous cross-sectional, multi-institutional survey of New England general surgery residents using novel and published instruments to create three domains: health maintenance, burnout, and work environment. RESULTS: Overall, 75% (15 of 20) of programs participated. The response rate was 44% (250 of 570), and 53% (133 of 250) were women, 94% (234 of 250) were 25 to 34 years old, and 71% (178 of 250) were in a relationship. For health maintenance, 57% (143 of 250) reported having a primary care provider, 26% (64 of 250) had not seen a primary care provider in 2 years, and 59% (147 of 250) endorsed being up to date with age-appropriate health screening, but only 44% (109 of 250) were found to actually be up to date. Only 14% (35 of 250) reported exercising more than 150 minutes/week. The burnout rate was 19% (47 of 250), with 32% (81 of 250) and 25% (63 of 250) reporting high levels of emotional exhaustion and depersonalization, respectively. For program directors and attendings, 90% of residents reported that they cared about resident well-being. Eighty-seven percent of residents believed that it was acceptable to take time off during the workday for a personal appointment, but only 49% reported that they would personally take the time. CONCLUSIONS: The personal health maintenance of general surgery residents has changed little over the past five years, despite an overwhelming majority of residents reporting that attendings and program directors care about their well-being. Further study is needed to understand the barriers to improvement of resident wellbeing.

General Surgery Going Viral: Current Trends in Social Media Utilization by General Surgery Residency Programs.

OBJECTIVE: This study examined the current and changing trends in utilization of social media platforms by general surgery residency programs. DESIGN: US general surgery residency programs were identified. Facebook, Instagram, and Twitter were surveyed for active accounts specific to an institution's general surgery residency program. Metrics for these accounts included: Date of first post/date of account creation, total number of posts, number of followers, number of posts categorized per year for 2017, 2018, 2019, 2020, and 2021. Active accounts were categorized into university based, university affiliated, or independent programs. Number of followers and the number of posts were compared among those categories. Data collection took place from 7/21/2021 - 8/2/2021. RESULTS: 295 social media accounts were identified. 55% of all programs have at least one social media account. Instagram (47.8%) and Twitter (36.3%) make up the majority of the social media accounts. The majority of all social media accounts (51.2%) were created in 2020. Instagram saw the largest increase in activity in 2020 with posting increasing by 403.7% compared to 2019. Twitter accounts had the highest amount of posts in 2020 (9940). Instagram accounts have the highest follower base (113,499). Facebook also saw increased posting in 2020 but its overall account creation has remained stagnant. University based program accounts have higher on average followers and posts when compared to independent program accounts. CONCLUSION: Social media accounts specific to general surgery residency programs have grown steadily in the past few years, with a dramatic rise of account creation and activity in 2020. Instagram and Twitter serve as the dominant platforms for new account creation and activity. University based programs attract more followers than independent programs on Instagram and Twitter.

"It's a Big Part of Being Good Surgeons": Surgical Trainees' Perceptions of Error Recovery in the Operating Room.

BACKGROUND: The burden of surgical error is high - errors threaten patient safety, lead to increased economic costs to society, and contribute to physician and resident burnout. To date, the majority of work has focused on strategies for reducing the incidence of surgical error, however, total error eradication remains unrealistic. Errors are, to some extent, unavoidable. Adequate preparation for practice should include optimal ways to manage and recover from errors; yet, these skills are rarely taught or assessed. OBJECTIVES: This study aims to explore residents' perceptions and experiences of surgical error recovery. More specifically, we documented participant definitions of error recovery, and explored factors that were perceived to influence error recovery experiences and training in the operating room. METHOD: Guided by a qualitative descriptive approach, we conducted semi-structured interviews with residents and fellows in surgical specialties in Canada and the United States. Purposive and snowball sampling were used to recruit residents and fellows in postgraduate year 1 to 5. Interviews were transcribed, analyzed and inductively coded. RESULTS: A total of 15 residents and fellows participated. When exploring the importance of error recovery for the trainees, competency and safety emerged as main themes, with error recovery being considered an indicator of overall surgical competency. Data concerning factors perceived to influence error recovery training were grouped under 4 major themes: (1) supervision (supervisor-related factors such as attending behaviors and reactions to errors), (2) self (factors such as self-assessed competency), (3) surgical context (factors related to the specific surgery or patient), and (4) situation safeness. Situational safeness was identified as a transversal theme describing factors to be considered when balancing between patient safety and the learning benefits of error recovery training. CONCLUSION: Error recovery was considered to be an important skill for safe surgical practice and was considered an important educational target for learners during surgical training. Trainees' opportunities to learn to recover from technical errors in the OR are perceived to be influenced by several factors, leading to variable experiences and inconsistent opportunities to practice error recovery skills. Focusing on factors related to "supervision," "self," "surgery," and "situational safeness" may be an initial framework on which to build initial educational interventions to support the development of error recovery skills to better support safe surgical practice.

Open-label, sham-controlled trial of an endoscopic duodenojejunal bypass liner for preoperative weight loss in bariatric surgery candidates.

BACKGROUND: The duodenojejunal bypass liner (DJBL) (EndoBarrier Gastrointestinal Liner) is an endoscopically placed and removable intestinal liner that creates a duodenojejunal bypass resulting in weight loss and improvement in type 2 diabetes mellitus. OBJECTIVE: Weight loss before bariatric surgery to decrease perioperative complications. DESIGN: Prospective, randomized, sham-controlled trial. SETTING: Multicenter, tertiary care, teaching hospitals. PATIENTS: Twenty-one obese subjects in the DJBL arm and 26 obese subjects in the sham arm composed the intent-to-treat population. INTERVENTIONS: The subjects in the sham arm underwent an EGD and mock implantation. Both groups received identical nutritional counseling. MAIN OUTCOME MEASUREMENTS: The primary endpoint was the difference in the percentage of excess weight loss (EWL) at week 12 between the 2 groups. Secondary endpoints were the percentage of subjects achieving 10% EWL, total weight change, and device safety. RESULTS: Thirteen DJBL arm subjects and 24 sham arm subjects completed the 12-week study. EWL was 11.9% +/- 1.4% and 2.7% +/- 2.0% for the DJBL and sham arms, respectively (P < .05). In the DJBL arm, 62% achieved 10% or more EWL compared with 17% of the subjects in the sham arm (P < .05). Total weight change in the DJBL arm was -8.2 +/- 1.3 kg compared with -2.1 +/- 1.1 kg in the sham arm (P < .05). Eight DJBL subjects terminated early because of GI bleeding (n = 3), abdominal pain (n = 2), nausea and vomiting (n = 2), and an unrelated preexisting illness (n = 1). None had further clinical symptoms after DJBL explantation. LIMITATIONS: Study personnel were not blinded. There was a lack of data on caloric intake. CONCLUSIONS: The DJBL achieved endoscopic duodenal exclusion and promoted significant weight loss beyond a minimal sham effect in candidates for bariatric surgery. ( CLINICAL TRIAL REGISTRATION NUMBER: NPT00469391.).

Obesity: Surgical and Device Interventions.

Bariatric surgery remains the most effective intervention for long-term sustained weight loss and resolution of comorbidities. It should be considered for patients with a body mass index of 40 kg/m2 or greater regardless of comorbidities and for patients with a body mass index of 30 kg/m2 with significant comorbidities, such as diabetes and sleep apnea. For these patients, laparoscopic bariatric surgery, including sleeve gastrectomy, Roux-en-Y gastric bypass, and duodenal switch, is safe with minimal perioperative risks of morbidity and mortality. Surgical management is associated with a survival benefit and resolution of common morbidities compared with nonsurgical management, despite the risk of postsurgical complications. These include gastroesophageal reflux disease, weight regain, bleeding, infection, and deep venous thrombosis. All patients who have undergone bariatric surgery require lifelong follow-up, including vitamin supplementation, annual laboratory testing, and multidisciplinary care (eg, dietary and psychological support). Bariatric surgery also has been shown to be safe in appropriate adolescent and elderly patients.

Surgical Errors Happen, but Are Learners Trained to Recover from Them? A Survey of North American Surgical Residents and Fellows.

BACKGROUND: Surgical training necessitates graded supervision and supported independence in order to reach competence. In developing surgical skills, trainees can, and will, make mistakes. A key skill required for independent practice is the ability to recover from an error or unexpected complication. Error recovery includes recognizing and managing a technical error in order to ensure patient safety and may be underrepresented in current educational approaches. OBJECTIVE: The purpose of this study is to explore residents' experiences and perceptions of error recovery training in surgical procedures. METHOD: An online survey was sent to surgical program directors in the United States and Canada using the Accreditation Council for Graduate Medical Education and the Royal College of Physicians and Surgeons of Canada distribution lists. Participating programs distributed the survey to their residents and fellows. The survey was composed of Likert-scale items, yes/no questions as well as open-ended questions focused on perceptions, experiences, and factors that influence to error recovery training in the operating room. RESULTS: A total of 206 surveys were completed. Overall, 99% (n = 203) agreed or strongly agreed that error recovery is an important competency for future practice. This was reflected in free-text response: "Errors can be minimized but they are inevitable, so certainly believe a surgical curriculum that addresses error recovery is of paramount importance." While 83% (n = 170) feel confident recovering from minor errors, only 34% (n = 68) feel confident that they could recover from major errors that are likely to have serious consequences on patient safety. Overall, residents do not consider that they have adequate training in error recovery, with only 37% (n = 72) felt they were adequately trained to recover from major errors. It was also mentioned "The quality of learning regarding error recovery depends entirely on the attending." CONCLUSIONS: Opportunities to learn to recover from technical errors in the operating room are valued by surgical trainees, but they perceive their training to be both inadequate and variable. This contributes to a lack of confidence in error recovery skills throughout their surgical training. There is a need to explore how best to integrate error recovery into more formal surgical curricula in order to better support learners and, ultimately, contribute to increased surgical safety.

Development and Validation of a Novel Surgical Simulation for Parotidectomy and Facial Nerve Dissection.

We present the development and validation of a low-cost novel model for training of parotid surgery. The model consists of a 3-dimensionally printed skeleton, silicone-based soft tissue, and facial nerve replicated with copper wire, circuited to indicate contact with instruments. The face validity of the simulator was evaluated with a 21-item 5-point Likert survey. Content validity was evaluated through a survey completed by the trainees after their first live parotidectomy following the simulation. Twelve residents and 6 faculty completed the simulated procedure of superficial parotidectomy after watching a video demonstration. Completion of 16 surgical steps evaluated by this model was graded for each participant. The mean ± SD total assessment score for faculty was 15.83 ± 0.41, as compared with 13.33 ± 2.06 for residents (P = .0081). The simulator as a training tool was well received by both faculty and residents (5 vs 4, P = .0206). Participants strongly agreed that junior residents would benefits from use of the model.

Practicing on the Advanced Training in Laparoscopic Suturing Curriculum (ATLAS): Is Mastery Learning in Residency Feasible to Achieve Expert-Level Performance in Laparoscopic Suturing?

BACKGROUND: Mastery learning assumes that given enough time and appropriate instructional strategies, most trainees will be able to achieve proficiency. Expert-level performance requires numerous hours of intensive and focus practice. We aimed to study whether it was possible for surgical trainees to achieve expert-derived proficiency level in laparoscopic suturing using the Advanced Training in Laparoscopic Suturing (ATLAS) curriculum over a short period of time. STUDY DESIGN: A multicenter IRB approved prospective study included surgery residents and minimally invasive fellows. Participants underwent weekly supervised instruction and assessments of ATLAS skills and self-directed practice between sessions over 12 weeks. Participants were asked to practice until they achieved previously established proficiency benchmarks of expert laparoscopic surgeons. RESULTS: Fifteen participants, PGY2 to PGY6, from 3 institutions practiced on the ATLAS curriculum. Three participants were able to achieve proficiency on the entire curriculum, with a cumulative practice time varying between 3.4 and 7.6 hours. Individual tasks had varying degrees of difficulty ranging from 85% proficiency on task 1 to 33.3% proficiency for task 6. Using a mixed-method model, the mean cumulative hours of practice to reach the benchmark threshold was estimated for each task and varied from 4.5 to 13.2 hours. The improved performance was associated with higher PGY level and proficiency in FLS. CONCLUSIONS: This study demonstrates that it is possible for some senior surgical trainees to achieve proficiency in an expert-level laparoscopic suturing curriculum. This study establishes a learning curve for each ATLAS individual task. Some learners may not be able to achieve proficiency on the entire curriculum over a short period of practice. Additional studies are needed to assess how to shorten the learning curve with effective instructional methods such as expert-guided training with immediate feedback.

Can genetics help predict efficacy of bariatric surgery? An analysis of microRNA profiles.

BACKGROUND: There is significant variability in weight loss after bariatric surgery. We hypothesize that part of this variability may be predetermined by genetic differences associated with metabolic homeostasis. MicroRNA (miRNA) are short pieces of RNA that regulate gene expression and are readily detectable in serum. They are implicated in numerous metabolic processes, including weight homeostasis. In this pilot study, we briefly review the role of miRNA, and assess the feasibility of using them in the clinical setting of obesity treatment. OBJECTIVES: To evaluate the feasibility of using miRNA to predict weight loss after bariatric surgery. SETTING: Academic medical center. METHODS: Serum was collected from patients at the initial bariatric surgery consultation. Weight loss data were collected 6 to 12 months postoperatively. Individuals experiencing the least and the greatest amount of percentage of excess weight lost at 6 months were analyzed to assess for genetic differences in miRNA expression. RESULTS: The median percentage of excess weight lost was 51% (range, 34%-63%) for those who lost the least and 87% (range, 82%-111%) for those who lost the most weight. Groups were similar in age, sex, diabetic status, and type of surgery. In total, of the 119 miRNA detected in the serum of the patients, 6 demonstrated potential for discriminating between the high and low weight loss groups. These miRNA have previously been implicated in regulation of fatty acid biosynthesis, adipocyte proliferation, type 2 diabetes, and obesity. CONCLUSIONS: In this pilot study, we demonstrated the feasibility of identifying genetic differences between high and low weight loss groups by identifying distinct serum miRNA. In the near future, these biomarkers could facilitate informed decisions about surgery. In addition, these miRNA could open new genetic pathways that describe the pathophysiology of obesity, and provide targets for future treatment.