Learning curve of robot-assisted transabdominal preperitoneal (rTAPP) inguinal hernia repair: a cumulative sum (CUSUM) analysis.

BACKGROUND: Robot-assisted transabdominal preperitoneal inguinal hernia repair (rTAPP-IHR) is a safe and feasible approach for hernias of varying etiology. We aim to present a single surgeon's learning curve (LC) of this technique based on operative times, while accounting for bilaterality and complexity. METHODS: This is a retrospective cohort analysis of patients who underwent rTAPP-IHR over a period of 5 years. Patients who underwent primary, recurrent, and complex (previous posterior repair, previous prostatectomy, scrotal, incarcerated) repairs were included. Cumulative and risk-adjusted cumulative sum analyses (CUSUM and RA-CUSUM) were used to depict the evolution of skin-to-skin times and complications/surgical site events (SSEs) with time, respectively. RESULTS: A total of 371 patients were included in the study. Mean skin-to-skin times were stratified according to four subgroups: unilateral non-complex (46.8 min), unilateral complex (63.2 min), bilateral non-complex (70.9 min), and bilateral complex (102 min). A CUSUM-LC was then plotted using each procedures difference in operative time from its subgroup mean. The peak of the plot occurred at case number 138, which was used as a transition between 'early' and 'late' phases. The average operative time for the late phase was 15.9 min shorter than the early phase (p < 0.001). The RA-CUSUM, plotted using the weight of case complexity and unilateral/bilateral status, also showed decreasing SSE rates after the completion of 138 cases (early phase: 8.8% vs. late phase: 2.2%, p = 0.008). Overall complication rates did not differ significantly between the two phases. CONCLUSIONS: Our study shows that regardless of bilateral or complex status, rTAPP operative times and SSE rates gradually decreased after completing 138 procedures. Previous laparoscopic experience, robotic team efficiency, and surgical knowledge are important considerations for a surgeon's LC.

A Fast-Track Pathway for Emergency General Surgery at an Academic Medical Center.

BACKGROUND: Fast Track Pathways (FTP) directed at reducing length of stay (LOS) and overall costs are being increasingly implemented for emergency surgeries. The purpose of this study is to evaluate implementation of a FTP for Emergency General Surgery (EGS) at an academic medical center (AMC). METHODS: The study included 165 patients at an AMC between 2016 and 2018 who underwent laparoscopic appendectomy (LA), laparoscopic cholecystectomy (LC), or laparoscopic inguinal hernia repair (LI). The FTP group enrolled 89 patients, and 76 controls prior to FTP implementation were evaluated. Time to surgery (TTS), LOS, and post-operative LOS between groups were compared. Direct costs, reimbursements, and patient reported satisfaction (satisfaction 1 = never, 4 = always) were also studied. RESULTS: The sample was 60.6% female, with a median age of 40 years. Case distribution differed slightly (56.2% versus 42.1% LA, 40.4% versus 57.9% LC, FTP versus control), but TTS was similar between groups (11h39min versus 10h02min, P = 0.633). LOS was significantly shorter in the FTP group (15h17min versus 29h09min, P < 0.001), reflected by shorter post-operative LOS (3h11min versus 20h10min, P< 0.001), fewer patients requiring a hospital bed and overnight stay (P < 0.001). Direct costs were significantly lower in the FTP group, reimbursements were similar (P < 0.001 and P = 0.999 respectively), and average patient reported satisfaction was good (3.3/4). CONCLUSION: In an era focused on decreasing cost, optimizing resources, and ensuring patient satisfaction, a FTP can play a significant role in EGS. At an AMC, an EGS FTP significantly decreased LOS, hospital bed utilization while not impacting reimbursement or patient satisfaction.

Learning Curve of Robotic Rives-Stoppa Ventral Hernia Repair: A Cumulative Sum Analysis.

Background: Robotic Rives-Stoppa ventral hernia repair (rRS-VHR) is a minimally invasive technique that incorporates extraperitoneal mesh placement, using either transabdominal or totally extraperitoneal access. An understanding of its learning curve and technical challenges may guide and encourage its adoption. We aim at evaluating the rRS-VHR learning curve based on operative times while accounting for adverse outcomes. Materials and Methods: We conducted a retrospective analysis of patients undergoing rRS repair for centrally located ventral and incisional hernias. A single surgeon operative time-based cumulative sum (CUSUM) analysis learning curve was created, and a composite outcome was used for risk-adjusted CUSUM (RA-CUSUM). Results: Eighty-one patients undergoing rRS-VHR were included. A learning curve was created by using skin-to-skin times. Accordingly, patients were grouped into three phases. The mean skin-to-skin time was 72.2 minutes, and there was a significant decrease in skin-to-skin times throughout the learning curve (Phase-I: 86.4 minutes versus Phase-III: 63.8 minutes; P = .001), with a gradual decrease after 29 cases. Eleven patients experienced adverse composite outcomes, which were used to create a RA-CUSUM graph. Results showed the highest adverse outcome rates in Phase-II, with a gradual decrease in risk-adjusted operative times after 51 cases. Conclusions: Consistently decreasing operative times and adverse outcome rates in rRS-VHR was observed after the completion of 29 and 51 cases, respectively. Future studies that provide group learning curves for this procedure can deliver more generalizable results in terms of its performance rates.

Learning Curve in Robotic Primary Ventral Hernia Repair Using Intraperitoneal Onlay Mesh: A Cumulative Sum Analysis.

BACKGROUND: Cumulative sum (CUSUM) learning curves (LCs) are useful to analyze individual performance and to evaluate the acquisition of new skills and the evolution of those skills as experience is accumulated. The purpose of this study is to present a CUSUM LC based on the operative times of robotic intraperitoneal onlay mesh (rIPOM) ventral hernia repair (VHR) and identify differences observed throughout its phases. MATERIALS AND METHODS: Patients who underwent rIPOM repair for elective, midline, and primary hernias were included. All procedures were performed exclusively by one surgeon within a 5-year period. CUSUM and risk-adjusted CUSUM were used to visualize the LC of rIPOM-VHR, based on operative times and complications. Once groups were obtained, univariate comparisons were performed. RESULTS: Of the 90 rIPOM repairs, 25, 40, and 25 patients were allocated using a CUSUM analysis to the early, middle, and late phases, respectively. In terms of skin-to-skin times, the middle phase has a mean duration of 23 minutes shorter than the early phase (P<0.001), and the late phase has a mean duration 34 minutes shorter than the early phase (P<0.001). A steep decrease in off-console time was observed, with a 10-minute difference from early to middle phases. A consistent and gradual decrease in operative times was observed after completion of 36 cases, and a risk-adjusted CUSUM revealed improving outcomes after 55 cases. CONCLUSIONS: This study demonstrates and elucidates interval improvement in operative efficiency in rIPOM-VHR. Consistently decreasing operative times and simultaneous accumulated complication rates were observed after the completion of 55 cases.

Treatment of Facial Fractures at a Level 1 Trauma Center: Do Medicaid and Non-Medicaid Enrollees Receive the Same Care?

BACKGROUND: Timing of surgical treatment of facial fractures may vary with the patient age, injury type, and presence of polytrauma. Previous studies using national data sets have suggested that trauma patients with government insurance experience fewer operations, longer length of hospital stay (LOS), and worse outcomes compared with privately insured patients. The objective of this study is to compare treatment of facial fractures in patients with and without Medicaid insurance (excluding Medicare). METHODS: All adults with mandibular, orbital, and midface fractures at a Level 1 Trauma Center between 2009 and 2018 were included. Statistical analyses were performed to assess the differences in the frequency of surgery, time to surgery (TTS), LOS, and mortality based on insurance type. RESULTS: The sample included 1541 patients with facial fractures (mandible, midface, orbital), of whom 78.8% were male, and 13.1% (208) were enrolled in Medicaid. Mechanism of injury was predominantly assault for Medicaid enrollees and falls or motor vehicle accidents for non-Medicaid enrollees (P < 0.001). Patients with mandible and midface fractures underwent similar rates of surgical repair. Medicaid enrollees with orbital fractures underwent less frequent surgery for facial fractures (24.8% versus 34.7%, P = 0.0443) and had higher rates of alcohol and drug intoxication compared with non-Medicaid enrollees (42.8% versus 31.6%, P = 0.008). TTS, LOS, and mortality were similar in both groups with facial fractures. CONCLUSIONS: Overall, the treatment of facial fractures was similar regardless of the insurance type, but Medicaid enrollees with orbital fractures experienced less frequent surgery for facial fractures. Further studies are needed to identify specific socioeconomic and geographic factors contributing to these disparities in care.

Treatment of Acute Cholecystitis: Do Medicaid and Non-Medicaid Enrolled Patients Receive the Same Care?

BACKGROUND: Nationally, Medicaid enrollees with emergency surgical conditions experience worse outcomes overall when compared with privately insured patients. The goal of this study is to investigate disparities in the treatment of cholecystitis based on insurance type and to identify contributing factors. METHODS: Adults with cholecystitis at a safety-net hospital in Central Massachusetts from 2017-2018 were included. Sociodemographic and clinical characteristics were compared based on Medicaid enrollment status (Medicare excluded). Univariate and multivariate analyses were used to compare the frequency of surgery, time to surgery (TTS), length of stay (LOS), and readmission rates between groups. RESULTS: The sample (n = 203) included 69 Medicaid enrollees (34%), with a mean age of 44.4 years. Medicaid enrollees were younger (p = 0.0006), had lower levels of formal education (high school diploma attainment, p < 0.0001), were more likely to be unmarried (p < 0.0001), Non-White (p = 0.0012), and require an interpreter (p < 0.0001). Patients in both groups experienced similar rates of laparoscopic cholecystectomy, TTS, and LOS; however, Medicaid enrollees experienced more readmissions within 30 days of discharge (30.4% vs 17.9%, p < 0.001). CONCLUSION: Despite anticipated population differences, the treatment of acute cholecystitis was similar between Medicaid and Non-Medicaid enrollees, with the exception of readmission. Further research is needed to identify patient, provider, and/or population factors driving this disparity.

Treatment of appendicitis: Do Medicaid and non-Medicaid-enrolled patients receive the same care?

BACKGROUND: Studies using national data sets have suggested that insurance type drives a disparity in the care of emergency surgery patients. Large databases lack the granularity that smaller, single-institution series may provide. The goal of this study is to identify factors that may account for differences in care between Medicaid and non-Medicaid enrollees with appendicitis in central Massachusetts. METHODS: All adult patients with acute appendicitis in an academic medical center between 2010 and 2018 were included. Sociodemographic and clinical characteristics were compared according to Medicaid enrollment status. Analyses were performed to assess differences in the frequency of operative treatment, time to surgery, length of stay, and rates of readmission. RESULTS: The sample included 1,257 patients, 10.7% of whom (n = 135) were enrolled in Medicaid. The proportions of patients presenting with perforated appendicitis (28.9% vs 31.2%, P = .857) and undergoing laparoscopic appendectomy (96.3% vs 90.7%, P = .081) were similar between the 2 groups, as were length of stay (20 hours 30 minutes versus 22 hours 38 minutes, P = .109) and readmission rates (17.8% vs 14.5%, P = .683). Medicaid enrollees did experience somewhat greater time to surgery (6 hours 47 minutes versus 4 hours 49 minutes, P < .001). CONCLUSION: Despite anticipated differences in population, the treatment of appendicitis was similar between Medicaid and non-Medicaid enrollees. Medicaid enrollees experienced greater time to surgery; however, further studies are needed to explain this disparity in care.

Approach to the Diagnostic Workup and Management of Small Bowel Lesions at a Tertiary Care Center.

BACKGROUND: Small bowel lesions (SBL) are rare, representing diagnostic and management challenges. The purpose of this cross-sectional study was to evaluate diagnostic modalities used and management practices of patients with SBL at an advanced endoscopic referral center. METHODS: We analyzed patients undergoing surgical management for SBL from 2005 to 2015 at a single tertiary care center. Patients were stratified into gastrointestinal bleed/anemia (GIBA) or obstruction/pain (OP). RESULTS: One hundred and twelve patients underwent surgery after presenting with either GIBA (n = 67) or OP (n = 45). The mean age of our study population was 61.8 years and 45% were women. Patients with GIBA were more likely to have chronic or acute-on-chronic symptoms (100% vs 67%) and more often referred from outside hospitals (82 vs. 44%) (p < 0.01). The most common preoperative imaging modalities were video capsule endoscopy (VCE) (96%) for GIBA and computer tomography CT (78%) for OP. Findings on VCE and CT were most frequently concordant with operative findings in GIBA (67%) and OP (54%) patients, respectively. Intraoperatively, visual inspection or palpation of the bowel successfully identified lesions in 71% of patients. When performed in GIBA (n = 26), intraoperative enteroscopy (IE) confirmed or identified lesions in 69% of patients. Almost all (90%) GIBA patients underwent small bowel resections; most were laparoscopic-assisted (93%). Among patients with OP, 58% had a small bowel resection and the majority (81%) were laparoscopic-assisted. Surgical exploration failed to identify lesions in 10% of GIBA patients and 24% of OP patients. Among patients who underwent resections, 20% of GIBA patients had recurrent symptoms compared with 13% of OP patients. CONCLUSION: Management and identification of SBL is governed by presenting symptomatology. Optimal management includes VCE and IE for GIBA and CT scans for OP patients. Comprehensive evaluation may require referral to specialized centers.

Cholecystostomy Treatment in an ICU Population: Complications and Risks.

BACKGROUND: Percutaneous cholecystostomy tube placement has widely been used as an alternative treatment to cholecystectomy, especially in advanced disease or critically ill patients. Reported postprocedural complication rates have varied significantly over the last decade. The goal of this study is to evaluate the safety of percutaneous cholecystostomy tube treatment in critically ill patients. STUDY DESIGN: We performed a retrospective chart analysis of 96 critically ill patients who underwent cholecystostomy tube placement during an intensive care unit (ICU) stay between 2005 and 2010 in a tertiary care center in central Massachusetts. Complications within 72 hours of cholecystostomy tube placement and any morbidity or mortality relating to presence of cholecystostomy tube were considered. RESULTS: A total of 65 male and 31 female patients with a mean age of 67.4 years underwent percutaneous cholecystostomy tube placement during an ICU stay. Sixty-six patients experienced a total of 121 complications, resulting in an overall complication rate of 69%. Fifty-four of these complications resulted from the actual procedure or the presence of the cholecystostomy tube; the other 67 complications occurred within 72 hours of the cholecystostomy procedure. Ten patients died. Tube dislodgment was the most common complication with a total of 34 episodes. CONCLUSIONS: Cholecystostomy tube placement is associated with frequent complications, the most common of which is tube dislodgment. Severe complications may contribute to serious morbidity and death in an ICU population. Complication rates may be underreported in the medical literature. The potential impact of cholecystostomy tube placement in critically ill patients should not be underestimated.

Timing and choice of intervention influences outcome in acute cholecystitis: a prospective study.

PURPOSE: Determine which management strategy is ideal for patients with acute cholecystitis. MATERIALS AND METHODS: Prospective enrollment between August 2009 and March 2011. Large academic center. Patients with acute cholecystitis. Laparoscopic cholecystectomy, intravenous antibiotics followed by laparoscopic cholecystectomy or percutaneous cholecystostomy. Primary endpoints were postoperative complications and 30-day mortality. RESULTS: A total of 162 patients were enrolled, 53 (33%) with simple acute cholecystitis and 109 (67%) with complex acute cholecystitis. Of the 109 patients with complex cholecystitis, 77 (70.6%) underwent successful laparoscopic cholecystectomy during the same hospital admission and 6 patients (5.5%) had an unsuccessful laparoscopic cholecystectomy requiring conversion to cholecystostomy. Radiology performed cholecystostomy in 19 (11.7%) patients with complex acute cholecystitis and 4 (2.5%) patients with simple acute cholecystitis for a total 23 patients of the 162 patients in the study. Nine of the 23 patients had dislodged tubes (39.1%). Two of the 23 patients (8.7%) had significant bile leaks resulting in either sepsis or emergency surgery. One patient (4.3%) had a wound infection. Overall, patients with complex acute cholecystitis had a higher morbidity rate (31.2%) compared with patients with simple acute cholecystitis (26.4%). CONCLUSIONS AND RELEVANCE: A high complication rate seen with radiology placed percutaneous cholecystostomy tubes prompted our center to reevaluate the treatment algorithm used to treat patients with complex acute cholecystitis. Although laparoscopic cholecystectomy is considered to be the gold standard in the treatment of acute cholecystitis, if laparoscopic cholecystectomy is not felt to be safe due to gallbladder wall thickening or symptoms of >72 hours' duration, we now encourage the use of intravenous antibiotics to "cool" patients down followed by interval laparoscopic cholecystectomy approximately 6 to 8 weeks later. Patients who do not respond to antibiotics should undergo attempted laparoscopic cholecystectomy and if unable to be performed safely, a laparoscopic cholecystostomy tube can be placed under direct visualization for decompression followed by interval laparoscopic cholecystectomy at a later date.

Use of cholecystostomy tubes in the management of patients with primary diagnosis of acute cholecystitis.

BACKGROUND: Management of patients with severe acute cholecystitis (AC) remains controversial. In settings where laparoscopic cholecystectomy (LC) can be technically challenging or medical risks are exceedingly high, surgeons can choose between different options, including LC conversion to open cholecystectomy or surgical cholecystostomy tube (CCT) placement, or initial percutaneous CCT. We reviewed our experience treating complicated AC with CCT at a tertiary-care academic medical center. STUDY DESIGN: All adult patients (n = 185) admitted with a primary diagnosis of AC and who received CCT from 2002 to 2010 were identified retrospectively through billing and diagnosis codes. RESULTS: Mean patient age was 71 years and 80% had ≥1 comorbidity (mean 2.6). Seventy-eight percent of CCTs were percutaneous CCT placement and 22% were surgical CCT placement. Median length of stay from CCT insertion to discharge was 4 days. The majority (57%) of patients eventually underwent cholecystectomy performed by 20 different surgeons in a median of 63 days post-CCT (range 3 to 1,055 days); of these, 86% underwent LC and 13% underwent open conversion or open cholecystectomy. In the radiology and surgical group, 50% and 80% underwent subsequent cholecystectomy, respectively, at a median of 63 and 60 days post-CCT. Whether surgical or percutaneous CCT placement, approximately the same proportion of patients (85% to 86%) underwent LC as definitive treatment. CONCLUSIONS: This 9-year experience shows that use of CCT in complicated AC can be a desirable alternative to open cholecystectomy that allows most patients to subsequently undergo LC. Additional studies are underway to determine the differences in cost, training paradigms, and quality of life in this increasingly high-risk surgical population.

Single-incision laparoscopic cholecystectomy using a modified dome-down approach with conventional laparoscopic instruments.

INTRODUCTION: Single-incision laparoscopic cholecystectomy (SILC) may increase the risk of bile duct injury due to compromised operative exposure. Dome-down laparoscopic cholecystectomy provides the ability to evaluate the cystic duct circumferentially prior to its division, thus minimizing the risks of bile duct injury. This study assesses the feasibility and safety of SILC using a modified dome-down approach with all conventional laparoscopic instruments. METHODS: Three low-profile 5-mm trocars are placed via a single transumbilical incision. The two working trocars are aimed laterally via the rectus to achieve adequate triangulation. An extralong 5-mm 30º laparoscope with an L-shaped light-cord adaptor is used to yield more external working space. Cephalic liver retraction is achieved with one transabdominal suture through the gallbladder fundus. Leaving the gallbladder fundus attached to the liver bed, a window is first created between the gallbladder body and the liver. The dissection is then carried down retrograde toward the porta hepatis. A 360º view of the gallbladder-cystic duct junction is achieved prior to transecting the cystic duct. The gallbladder is then freed by separation of the fundal attachments. The specimen is retrieved by enlarging the fascial incision. All fascial defects are then primarily closed. RESULTS: Sixteen patients (mean age 31 years, mean BMI 26.3 kg/m(2)) were enrolled in this study. Thirteen had elective surgery for symptomatic cholelithiasis, and three had emergency surgery for acute cholecystitis. Mean operating time was 80.3 min, and blood loss was minimal. All patients were discharged within 24 h without complications. Follow-up at 1 month revealed a barely visible scar within the umbilicus. CONCLUSIONS: SILC using a modified dome-down approach is technically feasible with all straight instruments, and it is safe because of good delineation of ductal anatomy. Adoption of this approach may minimize the risk of bile duct injury during early experience of SILC.

Evaluation of serum cytokine release in response to hand-assisted, laparoscopic, and open surgery in a porcine model.

BACKGROUND: Although the immunologic benefits of laparoscopic surgery have been established, effects from hand-assisted (HA) surgery have not been investigated thoroughly. We hypothesized that the HA approach maintains the immunologic advantage of laparoscopic surgery compared with the open (O) approach. METHODS: Six O, HA, and laparoscopic (L) transabdominal left nephrectomies were performed on pigs. Blood samples were taken preoperatively, perioperatively, and postoperatively, and serum interleukin-6 and C-reactive protein levels were measured. RESULTS: At 24 hours after surgery, interleukin-6 levels were significantly higher in the O group vs the HA and L groups (82.2 vs 37.5 and 29.9 pg/mL, respectively; P < .05). Similar trends were seen at all time periods for both IL-6 and C-reactive protein. No significant differences in postoperative cytokine levels were detected between the HA and L groups. CONCLUSIONS: The HA approach mimics the immunologic effects of laparoscopic surgery. These data suggest that the HA technique resulted in a reduced systemic immune activation in the early perioperative period when compared with open surgery. In addition to clinical benefits of minimal access, the HA approach also may afford patients an immunologic advantage over laparotomy.

Transforming the culture of surgical education: promoting teacher identity through human factors training.

CONTEXT: Promoting a culture of teaching may encourage students to choose a surgical career. Teaching in a human factors (HF) curriculum, the nontechnical skills of surgery, is associated with surgeons' stronger identity as teachers and with clinical students' improved perception of surgery and satisfaction with the clerkship experience. OBJECTIVE: To describe the effects of an HF curriculum on teaching culture in surgery. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTION: Surgeons and educators developed an HF curriculum including communication, teamwork, and work-life balance. MAIN OUTCOME MEASURES: Teacher identity, student interest in a surgical career, student perception of the HF curriculum, and teaching awards. RESULTS: Ninety-two of 123 faculty and residents in a single program (75% of total) completed a survey on teacher identity. Fifteen of the participants were teachers of HF. Teachers of HF scored higher than control participants on the total score for teacher identity (P < .001) and for subcategories of global teacher identity (P = .001), intrinsic satisfaction (P = .001), skills and knowledge (P = .006), belonging to a group of teachers (P < .001), feeling a responsibility to teach (P = .008), receiving rewards (P =.01), and HF (P = .02). Third-year clerks indicated that they were more likely to select surgery as their career after the clerkship and rated the curriculum higher when it was taught by surgeons than when taught by educators. Of the teaching awards presented to surgeons during HF years, 100% of those awarded to attending physicians and 80% of those awarded to residents went to teachers of HF. CONCLUSION: Curricular focus on HF can strengthen teacher identity, improve teacher evaluations, and promote surgery as a career choice.

Athletic pubalgia (sports hernia).

Athletic pubalgia or sports hernia is a syndrome of chronic lower abdomen and groin pain that may occur in athletes and nonathletes. Because the differential diagnosis of chronic lower abdomen and groin pain is so broad, only a small number of patients with chronic lower abdomen and groin pain fulfill the diagnostic criteria of athletic pubalgia (sports hernia). The literature published to date regarding the cause, pathogenesis, diagnosis, and treatment of sports hernias is confusing. This article summarizes the current information and our present approach to this chronic lower abdomen and groin pain syndrome.

A human factors curriculum for surgical clerkship students.

HYPOTHESIS: Early introduction of a full-day human factors training experience into the surgical clerkship curriculum will teach effective communication skills and strategies to gain professional satisfaction from a career in surgery. DESIGN: In pilot 1, which took place between July 1, 2007, and December 31, 2008, 50 students received training and 50 did not; all received testing at the end of the rotation for comparison of control vs intervention group performance. In pilot 2, a total of 50 students were trained and received testing before and after rotation to examine individual change over time. SETTING: University of Massachusetts Medical School. PARTICIPANTS: A total of 148 third-year medical students in required 12-week surgical clerkship rotations. INTERVENTIONS: Full-day training with lecture and small-group exercises, cotaught by surgeons and educators, with focus on empathetic communication, time management, and teamwork skills. MAIN OUTCOME MEASURES: Empathetic communication skill, teamwork, and patient safety attitudes and self-reported use of time management strategies. RESULTS: Empathy scores were not higher for trained vs untrained groups in pilot 1 but improved from 2.32 to 3.45 on a 5-point scale (P < .001) in pilot 2. Students also were more likely to ask for the nurse's perspective and to seek agreement on an action plan after team communication training (pilot 1, f = 7.52, P = .007; pilot 2, t = 2.65, P = .01). Results were mixed for work-life balance, with some trained groups scoring significantly lower than untrained groups in pilot 1 and no significant improvement shown in pilot 2. CONCLUSIONS: The significant increase in student-patient communication scores suggests that a brief focused presentation followed by simulation of difficult patient encounters can be successful. A video demonstration can improve interdisciplinary teamwork.

Human Emotion and Response in Surgery (HEARS): a simulation-based curriculum for communication skills, systems-based practice, and professionalism in surgical residency training.

BACKGROUND: This study examines the development and implementation of a pilot human factors curriculum during a 2-year period. It is one component of a comprehensive 5-year human factors curriculum spanning core competencies of interpersonal and communication skills, systems-based practice, and professionalism and using low-and high-fidelity simulation techniques. STUDY DESIGN: Members of the Department of Surgery and the Center for Clinical Communication and Performance Outcomes jointly constructed a curriculum for PGY1 and PGY2 residents on topics ranging from challenging communication to time and stress management. Video demonstrations, triggers, and simulated scenarios involving acting patients were created by surgeons and medical educators. Pre- and postintervention measures were obtained for communication skills, perceived stress level, and teamwork. Communication skills were evaluated using a series of video vignettes. The validated Perceived Stress Scale and Teamwork and Patient Safety Attitudes survey were used. Residents' perceptions of the program were also measured. RESULTS: Twenty-seven PGY1 residents and 15 PGY2 residents participated during 2 years. Analyses of video vignette tests indicated significant improvement in empathic communication for PGY1 (t = 3.62, p = 0.001) and PGY2 (t = 5.00, p = 0.004). There were no significant changes to teamwork attitudes. Perceived levels of stress became considerably higher. PGY1 residents reported trying 1 to 3 strategies taught in the time management session, with 60% to 75% reporting improvement post-training. CONCLUSIONS: This unique and comprehensive human factors curriculum is shown to be effective in building communication competency for junior-level residents in the human and emotional aspects of surgical training and practice. Continued refinement and ongoing data acquisition and analyses are underway.

Surgical management of acute cholecystitis at a tertiary care center in the modern era.

HYPOTHESIS: The advent of laparoscopy has changed the paradigm of surgical training and care delivery for the treatment of patients with acute cholecystitis (AC). DESIGN: Retrospective data collection and analysis. SETTING: Hospital admissions with a primary diagnosis of AC at a tertiary care center from January 1, 2002, to January 1, 2007. PATIENTS: During the study period, 923 patients were admitted with a primary diagnosis of AC. One hundred fourteen patients were excluded from the study because of missing data, medical management, incomplete operative notes or documents, or metastatic gastrointestinal cancer. MAIN OUTCOME MEASURES: Patient demographics, preoperative morbidity, procedures (medical and surgical), and postoperative outcomes were statistically analyzed using chi(2) test, t test, and analysis of variance. RESULTS: Eight hundred nine patients (87.6%) with a primary diagnosis of AC underwent surgery by 44 surgeons. Procedures included 663 laparoscopic cholecystectomies (LCs) (82.0%), 9 open cholecystectomies (1.1%), 51 conversions from LC to open cholecystectomy (6.3%), and 86 cholecystostomy tube placements (10.6%). During the study period, cholecystostomy tube placements increased, while open cholecystectomies and conversions from LC to open cholecystectomy decreased (P < .05). Laparoscopic cholecystectomy was associated with significantly better outcomes, including shorter postsurgical stay (2.2 vs 6.3 days for other modalities) and fewer complications (8.5% vs 17.0%). CONCLUSIONS: Based on 5-year results from a tertiary care center, LC was performed with a low conversion rate to open surgery and was associated with decreased morbidity and mortality compared with other surgical modalities to treat AC. Our data confirm the benefits and widespread use of LC in the modern era, reflecting changes in the training paradigm and learning curve for laparoscopy.

Trends in adrenalectomy: a recent national review.

BACKGROUND: Adrenalectomy remains the definitive therapy for most adrenal neoplasms. Introduced in the 1990s, laparoscopic adrenalectomy is reported to have lower associated morbidity and mortality. This study aimed to evaluate national adrenalectomy trends, including major postoperative complications and perioperative mortality. METHODS: The Nationwide Inpatient Sample was queried to identify all adrenalectomies performed during 1998-2006. Univariate and multivariate logistic regression were performed, with adjustments for patient age, sex, comorbidities, indication, year of surgery, laparoscopy, hospital teaching status, and hospital volume. Annual incidence, major in-hospital postoperative complications, and in-hospital mortality were evaluated. RESULTS: Using weighted national estimate, 40,363 patients with a mean age of 54 years were identified. Men made up 40% of these patients, and 77% of the patients were white. The majority of adrenalectomies (83%) were performed for benign disease. The annual volume of adrenalectomies increased from 3,241 in 1998 to 5,323 in 2006 (p < 0.0001, trend analysis). The overall in-hospital mortality was 1.1%, with no significant change. Advanced age (< 45 years as the referent; ≥ 65 years: adjusted odds ratio [AOR], 4.10; 95%; confidence Interval [CI], 1.66-10.10) and patient comorbidities (Charlson score 0 as the referent; Charlson score ≥ 2: AOR, 4.33; 96% CI, 2.34-8.02) were independent predictors of in-hospital mortality. Indication, year, hospital teaching status, and hospital volume did not independently affect perioperative mortality. Major postoperative in-hospital complications occurred in 7.2% of the cohort, with a significant increasing trend (1998-2000 [5.9%] vs 2004-2006 [8.1%]; p < 0.0001, trend analysis). Patient comorbidities (Charlson score 0 as the referent; Charlson score ≥ 2: AOR, 4.77; 95% CI, 3.71-6.14), recent year of surgery (1998-2000 as the referent; 2004-2006: AOR, 1.40; 95% CI, 1.09-1.78), and benign disease (malignant disease as the referent; benign disease: AOR, 1.98; 95% CI, 1.55-2.53) were predictive of major postoperative complications at multivariable analyses, whereas laparoscopy was protective (no laparoscopy as the referent; laparoscopy: AOR, 0.62; 95% CI, 0.47-0.82). CONCLUSION: Adrenalectomy is increasingly performed nationwide for both benign and malignant indications. In this study, whereas perioperative mortality remained low, major postoperative complications increased significantly.

Massachusetts health insurance mandate: effects on neurosurgical practice.

OBJECT: Massachusetts' health insurance mandate and subsidized insurance program, Commonwealth Care, have been active for 2 years. METHODS: The financial impact on the neurosurgery division and demographics of the relevant patient groups were assessed. The billing records of neurosurgical patients from January 2007 to September 2008 were collected and analyzed. RESULTS: Commonwealth Care comprised 2.2% of neurosurgical inpatients, and these patients did not have significantly different acuity or lengths of stay from the average. Length of stay of MassHealth patients was significantly greater, although acuity was significantly lower than the average. Increased free care reimbursement and increased MassHealth/Commonwealth Care enrollment resulted in a net gain in reimbursement of hospital charges. CONCLUSIONS: The increased insurance rates have resulted in increased reimbursement for the neurosurgical division.