A solution to the decreased resident exposure to open operations in the era of minimally invasive surgery and restricted duty hours may be with organ procurement and transplantation surgery.

INTRODUCTION: The surgical resident experience regarding open surgical procedures and techniques is being significantly limited by the maturation of minimally invasive surgery (MIS) and duty-hour restrictions. MIS has replaced many open procedures as the current standard of care. As MIS progresses, the surgical residents' access to open surgical techniques will become significantly limited by the lack of exposure to common open operations. METHODS: The Accreditation Council for Graduate Medical Education (ACGME) database was retrospectively reviewed to quantify and categorize resident experience in self-reported surgical procedures. The United Network for Organ Sharing (UNOS) database was retrospectively reviewed to determine the amount of organ transplants and procurements performed during the study period. Data from 1999-2000 and 2008-2009 were collected and compared. RESULTS: There were dramatic changes between the time periods regarding the transition from the open to the laparoscopic approach for multiple operations. In 2008, there were 23,276 transplanted organs and 29,077 organs procured (7990 multi-organ procurements). However, the graduating general surgery chief residents reported doing an average of 2 organ procurements and 7 organ transplantations over a 5-year period. This provides the opportunity for each graduating chief resident to perform 38 more procurements during their residency. CONCLUSION: It is imperative for surgical educators to find solutions to safely train the future general surgery residents to perform more surgical techniques in less time. One solution to this problem may lie within the field of organ transplantation and procurement. The field of organ transplantation and procurement may be an untapped resource for valuable exposure to the basic principles of open surgical techniques that are declining due to the advancement of MIS and mandated duty-hour restrictions.

Popliteal artery injuries in an urban trauma center with a rural catchment area: do delays in definitive treatment affect amputation?

Extended length of time from injury to definitive vascular repair is considered to be a predictor of amputation in patients with popliteal artery injuries. In an urban trauma center with a rural catchment area, logistical issues frequently result in treatment delays, which may affect limb salvage after vascular trauma. We examined how known risk factors for amputation after popliteal trauma are affected in a more rural environment, where patients often experience delays in definitive surgical treatment. All adult patients admitted to the Level I trauma center, the University of Mississippi Medical Center, with a popliteal artery injury between January 2000 and December of 2007 were identified. Demographic information management and outcome data were collected. Body mass index, mangled extremity severity score (MESS), Guistilo open fracture score, injury severity score, and time from injury to vascular repair were examined. Fifty-one patients with popliteal artery injuries (53% blunt and 47% penetrating) were identified, all undergoing operative repair. There were nine amputations (17.6%) and one death. Patients requiring amputation had a higher MESS, 7.8 versus 5.3 (P < 0.01), and length of stay, 43 versus 15 days (P < 0.01), compared with those with successful limb salvage. Body mass index, injury severity score, Guistilo open fracture score, or time from injury to repair were not different between the two groups. Patients with a blunt mechanism of injury had a slightly higher amputation rate compared with those with penetrating trauma, 25.9 per cent versus 8.3 per cent (P = non significant). MESS, though not perfect, is the best predictor of amputation in patients with popliteal artery injuries. Morbid obesity is not a significant predictor for amputation in patients with popliteal artery injuries. Time from injury to repair of greater than 6 hours was not predictive of amputation. This study further demonstrates that a single scoring system should be used with caution when determining the need for lower extremity amputation.

Stapled intestinal anastomosis in neonates: validation of safety and efficacy.

The safety and effectiveness of a stapled intestinal anastomosis in adults and children is well documented. However, the role of this technique in neonates is not well validated. We report our experience with stapled intestinal anastomoses in the neonate at the University of Mississippi Medical Center. All patients from the neonatal intensive care unit who had a stapled intestinal anastomosis between February 2007 and May 2008 were identified. A stapled side-to-side functional end-to-end intestinal anastomosis was performed in all patients using a gastrointestinal anastomosis stapler. Demographic, management, and outcome data were collected via chart review. Variables collected included: birth weight, estimated gestational age at birth and surgery, weight at surgery, the use of vasopressors, associated diagnoses, location of the anastomosis, and postoperative clinic visits. A total of 18 patients were identified during the study period. Nine had small bowel to small bowel, eight had ileum to colon, and one had a colon to colon anastomosis. The average weight at time of operation was 2.8 kilograms (Kg) and the average estimated gestational age at surgery was 38.7 weeks. The only complication reported was a partial small bowel obstruction on postoperative day 12, which was successfully treated nonoperatively. Two patients died from problems not associated with the anastomosis. There were no anastomotic leaks or strictures. The literature regarding the use of stapled bowel anastomoses in neonates is scant. Stapled intestinal anastomoses can be performed safely in neonates without a high rate of complication. The long-term effects of stapled intestinal anastomoses in the neonate are unknown. Future areas of interest would include effects on postoperative feeding and operative time.