The Impact of Trainee Involvement on Outcomes in Metabolic and Bariatric Surgery.

BACKGROUND: The number of bariatric operations performed in the USA rises annually. Trainee exposure to this field is necessary to ensure competency in future surgical generations. However, the safety of trainee involvement of these operations has been called into question. OBJECTIVES: The aim of our study is to describe differences in outcomes between trainees and non-trainees as first assistants (FA) in sleeve gastrectomy (SG). SETTING: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database METHODS: Patients from the MBSAQIP database who underwent primary SG from 2015 to 2020 were identified. Statistical analysis included two-tailed t-tests and χ2-tests to evaluate the impact of trainees (residents and fellows) compared to non-trainees on post-operative morbidity and operative time. RESULTS: Of the 559,324 cases, 25.8% were performed with trainees as FA. Operative length was 27.9% longer in trainee cases. In the trainee group, there was a higher risk of conversion to open procedure (OR 1.32), readmission (OR 1.19), and specific complications (cardiac arrest, myocardial infarction, progressive renal insufficiency, pulmonary embolism, sepsis, transfusion, intubation, UTI, VTE, ICU admission, and reintervention), though overall rates were < 1% in each group. Non-trainees had a higher rate of septic shock (OR 1.4). No significant difference was seen in all other perioperative outcomes. CONCLUSION: Trainee involvement in SG leads to longer operative times without a clinically significant increase in morbidity and mortality. Such findings should be used to counsel patients and shape expectations for surgeons and hospitals. A focused bariatric surgery trainee curriculum may lessen this gap.

Safer operating room teams: rationale for the fundamental use of surgical energy (FUSE) hospital compliance module.

BACKGROUND: The Fundamental Use of Surgical Energy (FUSE) program was developed by The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to promote the safe use of surgical energy. A curriculum that could be used in hospital educational programs was needed to expand access. The goal of this project was to develop a short, inexpensive, online module that emphasizes key FUSE learning objectives. The accompanying survey assessed perceived relevancy. METHODS: The SAGES FUSE Committee developed the Hospital Compliance Module. The target audience included all OR personnel. The Module was piloted at Beth Israel Deaconess Medical Center. The data were analyzed using Chi-square with Yates' correction two-tailed test. RESULTS: Three-hundred-eighty individuals completed the survey: 198 (52%) surgeons, 139 (37%) nurses, 28 (7%) surgical technicians, and 15 (4%) house staff. For "…the Module taught me valuable information" 155 (41%) responded extremely and 350 (92%) responded at least somewhat. For "As a result of [the Module] how likely are you to change how you set up or use energy devices…?" 103 (27%) responded extremely and 305 (80%) responded at least somewhat. For "How likely are you to recommend this compliance module…?" 143 (38%) responded extremely and 333 (88%) responded at least somewhat. CONCLUSION: The FUSE Hospital Compliance Module is effective and efficient. It should be considered for widespread distribution by hospitals to enhance staff education.

Team training and surgical crisis management.

Team training and crisis management derive their roots from fundamental learning theory and the culture of safety that burgeoned forth from the industrial revolution through the rise of nuclear energy and aviation. The integral nature of telemedicine to many simulation-based activities, whether to bridge distances out of convenience or necessity, continues to be a common theme moving into the next era of surgical safety as newer, more robust technologies become available.

Identification of Specific Educational Targets to Improve the Student Surgical Clerkship Experience.

BACKGROUND: This study describes the relationship between medical student perception of surgery, frequency of positive surgery clerkship activities, and overall surgical clerkship experience. METHODS: Medical students at four academic hospitals completed pre- and post-clerkship surveys assessing 1) surgery clerkship activities/experiences and 2) perceptions of surgery during the 2017-2018 academic year. RESULTS: Ninety-one percent of students completed both a pre- and post-clerkship survey (n = 162 of 179). Student perception of surgery significantly improved across the clerkship overall (P < 0.0001) and for 7 of 21 specific items. Eighty-six percent of students agreed that the clerkship was a meaningful experience. Sixty-six percent agreed that the operating room was a positive learning environment. Multivariable logistic regression identified one-on-one mentoring from a resident (OR [95% CI] = 2.12 [1.11-4.04], P = 0.02) and establishing a meaningful relationship with a surgical patient (OR = 2.21 [1.12-4.37], P = 0.02) as activities predictive of student agreement that the surgical clerkship was meaningful. Making an incision (OR = 2.92 [1.54-5.56], P = 0.001) and assisting in dissection (OR = 1.67 [1.03-2.69], P = 0.035) were predictive of student agreement that the operating room was a positive learning environment. Positive student perception of surgery before the clerkship was associated with increased frequency of positive clerkship activities including operative involvement (r = 0.26, P = 0.001) and relationships with surgical attendings (r = 0.20, P = 0.01), residents (r = 0.41, P < 0.0001), and patients (r = 0.24, P = 0.003). CONCLUSIONS: Interventions to improve surgery clerkship quality should target enhancing student relationships with residents and surgical patients as well as providing opportunity for student operative involvement beyond just suturing. In addition, fostering positive perceptions of surgery in the preclinical period may increase meaningfulness and experience with the later surgery clerkship.

ACS/ASE Medical Student Simulation-Based Skills Curriculum Study: Implementation Phase.

OBJECTIVE: Patient safety initiatives have revealed a need for standardized medical student skills curricula. In 2014 the America College of Surgeons/Association for Surgical Education Medical Student Simulation-based Skills Research Collaborative initiated a multisite study to implement and study the effect of a skills curriculum during the surgical clerkship. DESIGN: Students underwent knot-tying and suturing sessions. They performed a self-evaluation survey before and after the modules to assess their comfort level with the skills. Faculty members also evaluated the students at the completion of the skills sessions. The comfort level choices were: needs further review; proficient in simulated setting with assistance; proficient in simulated setting without assistance; and proficient in clinical setting under supervision. RESULTS: At the completion of the modules greater than 99.3% and 98.5% of students reported that they were proficient in knot-tying and suturing, respectively, in either a simulated or clinical environment. Similarly, when faculty evaluated student performance after a session, simulated or clinically proficiency reached over 97% for both two-handed and instrument knot-tying. The faculty rated the students 86.6% proficient for suturing. CONCLUSIONS: After completing the modules, a large percentage of students obtained proficiency in knot-tying and suturing, representing technical skills improvements noted by both the participants and the evaluating faculty. The America College of Surgeons/Association for Surgical Education medical student surgical skills modules represent expert developed, low cost, easy to access resources that should continue to be evaluated and disseminated to medical student learners.

FUSE certification enhances performance on a virtual computer based simulator for dispersive electrode placement.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has developed the fundamental use of surgical energy (FUSE) didactic curriculum in order to further understanding of the safe use of surgical energy. The virtual electrosurgical skill trainer (VEST) is being developed as a complementary simulation-based curriculum, with several modules already existing. Subsequently, a new VEST module has been developed about dispersive electrode placement. The purpose of this study is to assess knowledge about dispersive electrode placement in surgeons and surgical trainees in addition to describing a new VEST module. METHODS: Forty-six subjects (n = 46) were recruited for participation at the 2016 SAGES conference Learning Center. Subjects were asked to complete demographic surveys, a five-question pre-test, and a five-question post-test after completing the VEST dispersive electrode module. Subjects were then asked to rate different aspects of the module using a five-point Likert scale questionnaire. RESULTS: Mean pre-simulator and post-simulator assessment scores were 1.5 and 3.4, respectively, with Wilcoxon signed rank analysis showing a significant difference in the means (p < 0.05). Subjects were grouped by the presence (n = 12) or absence (n = 31) of prior FUSE experience and by training level. Mann-Whitney U testing showed no significant difference in pre-simulator assessment scores between attending surgeons and trainees (p > 0.05). In those with and without FUSE exposure, a significant difference (p < 0.05) was seen in pre-simulator assessment scores, and no significant difference in Likert scale assessment scores was seen. CONCLUSIONS: This study demonstrated a new VEST educational module. Consistently high Likert assessment scores showed that users felt that the VEST module helped their understanding of dispersive electrode placement. Additionally, the study reflected a potential knowledge deficit in the safe use of dispersive electrodes in the surgical community, also demonstrating that even some exposure to the FUSE curriculum developed by SAGES provides increased awareness about dispersive electrode use.

Immersive virtual reality-based training improves response in a simulated operating room fire scenario.

BACKGROUND: SAGES FUSE curriculum provides didactic knowledge on OR fire prevention. The objective of this study is to evaluate the impact of an immersive virtual reality (VR)-based OR fire training simulation system in combination with FUSE didactics. METHODS: The study compared a control with a simulation group. After a pre-test questionnaire that assessed the baseline knowledge, both groups were given didactic material that consists of a 10-min presentation and reading materials about precautions and stopping an OR fire from the FUSE manual. The simulation group practiced on the OR fire simulation for one session that consisted of five trials within a week from the pre-test. One week later, both groups were reassessed using a questionnaire. A week after the post-test both groups also participated in a simulated OR fire scenario while their performance was videotaped for assessment. RESULTS: A total of 20 subjects (ten per group) participated in this IRB approved study. Median test scores for the control group increased from 5.5 to 9.00 (p = 0.011) and for the simulation group it increased from 5.0 to 8.5 (p = 0.005). Both groups started at the same baseline (pre-test, p = 0.529) and reached similar level in cognitive knowledge (post-test, p = 0.853). However, when tested in the mock OR fire scenario, 70% of the simulation group subjects were able to perform the correct sequence of steps in extinguishing the simulated fire whereas only 20% subjects in the control group were able to do so (p = 0.003). The simulation group was better than control group in correctly identifying the oxidizer (p = 0.03) and ignition source (p = 0.014). CONCLUSIONS: Interactive VR-based hands-on training was found to be a relatively inexpensive and effective mode for teaching OR fire prevention and management scenarios.

Presacral mass in the setting of an ovarian cyst and abdominal pain.

Tailgut cysts, also known as retrorectal hamartomas, are very rare neoplasms located in the presacral/retrorectal space that originate from the embryonic hindgut. Although a majority of lesions in this location are benign, 30% of the reported cases in the literature were found to be malignant. This report describes a case of a presacral mass found on CT of a 37-year-old woman who initially presented with worsening abdominal pain and a history of ovarian cyst rupture. This patient's clinical picture was complicated by an enlarging ovarian cyst. The risk of progression to malignancy warranted excision. She recovered well with resolution of her presenting symptoms. We report this case along with a brief review of the literature with a focus on the surgical considerations.

OR fire virtual training simulator: design and face validity.

BACKGROUND: The Virtual Electrosurgical Skill Trainer is a tool for training surgeons the safe operation of electrosurgery tools in both open and minimally invasive surgery. This training includes a dedicated team-training module that focuses on operating room (OR) fire prevention and response. The module was developed to allow trainees, practicing surgeons, anesthesiologist, and nurses to interact with a virtual OR environment, which includes anesthesia apparatus, electrosurgical equipment, a virtual patient, and a fire extinguisher. Wearing a head-mounted display, participants must correctly identify the "fire triangle" elements and then successfully contain an OR fire. Within these virtual reality scenarios, trainees learn to react appropriately to the simulated emergency. A study targeted at establishing the face validity of the virtual OR fire simulator was undertaken at the 2015 Society of American Gastrointestinal and Endoscopic Surgeons conference. METHODS: Forty-nine subjects with varying experience participated in this Institutional Review Board-approved study. The subjects were asked to complete the OR fire training/prevention sequence in the VEST simulator. Subjects were then asked to answer a subjective preference questionnaire consisting of sixteen questions, focused on the usefulness and fidelity of the simulator. RESULTS: On a 5-point scale, 12 of 13 questions were rated at a mean of 3 or greater (92%). Five questions were rated above 4 (38%), particularly those focusing on the simulator effectiveness and its usefulness in OR fire safety training. A total of 33 of the 49 participants (67%) chose the virtual OR fire trainer over the traditional training methods such as a textbook or an animal model. CONCLUSIONS: Training for OR fire emergencies in fully immersive VR environments, such as the VEST trainer, may be the ideal training modality. The face validity of the OR fire training module of the VEST simulator was successfully established on many aspects of the simulation.

Basic airway skills acquisition using the American College of Surgeons/Association for Surgical Education medical student simulation-based surgical skills curriculum: Initial results.

BACKGROUND: The ACS/ASE Medical Student Simulation-Based Skills Curriculum was developed to standardize medical student training. This study aims to evaluate the feasibility and validity of implementing the basic airway curriculum. METHODS: This single-center, prospective study of medical students participating in the basic airway module from 12/2014-3/2016 consisted of didactics, small-group practice, and testing in a simulated clinical scenario. Proficiency was determined by a checklist of skills (1-15), global score (1-5), and letter grade (NR-needs review, PS-proficient in simulation scenario, CP-proficient in clinical scenario). A proportion of students completed pre/post-test surveys regarding experience, satisfaction, comfort, and self-perceived proficiency. RESULTS: Over 16 months, 240 students were enrolled with 98% deemed proficient in a simulated or clinical scenario. Pre/post-test surveys (n = 126) indicated improvement in self-perceived proficiency by 99% of learners. All students felt moderately to very comfortable performing basic airway skills and 94% had moderate to considerable satisfaction after completing the module. CONCLUSIONS: The ACS/ASE Surgical Skills Curriculum is a feasible and effective way to teach medical students basic airway skills using simulation.

Needs assessment for a focused radiology curriculum in surgical residency: a multicenter study.

BACKGROUND: Patient instability and limited radiology staffing may compel surgeons to make clinical decisions based on their independent interpretations of imaging studies. Despite potential implications for patients, no research to date has assessed the need for a diagnostic radiology curriculum in general surgery residency. METHODS: We performed a cross-sectional study of surgery faculty and residents at 13 teaching hospitals across the United States. Survey responses were summarized using frequency and percentage, and analyzed by chi-square, Mantel-Haenszel chi-square, and McNemar tests. RESULTS: Surveys were distributed to 465 faculty and 520 residents, with response rates of 26% and 30%, respectively. Most respondents reported making decisions based on their independent imaging interpretation at least sometimes, with higher frequency in acute scenarios. The majority voiced a need for a dedicated radiology curriculum, with teaching in chest x-rays, abdominal x-rays, abdominal computed tomography, chest computed tomography, and focused assessment with sonography in trauma examinations. CONCLUSIONS: Surgeons and surgical residents enact treatment plans based on their independent interpretation of imaging studies, especially during acute patient scenarios. Further curricular development efforts are warranted to ensure trainee accuracy in radiologic interpretation.

Fundamental Use of Surgical Energy (FUSE) certification: validation and predictors of success.

INTRODUCTION: The Fundamental Use of Surgical Energy (FUSE) program includes a Web-based didactic curriculum and a high-stakes multiple-choice question examination with the goal to provide certification of knowledge on the safe use of surgical energy-based devices. The purpose of this study was (1) to set a passing score through a psychometrically sound process and (2) to determine what pretest factors predicted passing the FUSE examination. METHODS: Beta-testing of multiple-choice questions on 62 topics of importance to the safe use of surgical energy-based devices was performed. Eligible test takers were physicians with a minimum of 1 year of surgical training who were recruited by FUSE task force members. A pretest survey collected baseline information. RESULTS: A total of 227 individuals completed the FUSE beta-test, and 208 completed the pretest survey. The passing/cut score for the first test form of the FUSE multiple-choice examination was determined using the modified Angoff methodology and for the second test form was determined using a linear equating methodology. The overall passing rate across the two examination forms was 81.5%. Self-reported time studying the FUSE Web-based curriculum for a minimum of >2 h was associated with a passing examination score (p < 0.001). Performance was not different based on increased years of surgical practice (p = 0.363), self-reported expertise on one or more types of energy-based devices (p = 0.683), participation in the FUSE postgraduate course (p = 0.426), or having reviewed the FUSE manual (p = 0.428). Logistic regression found that studying the FUSE didactics for >2 h predicted a passing score (OR 3.61; 95% CI 1.44-9.05; p = 0.006) independent of the other baseline characteristics recorded. CONCLUSION(S): The development of the FUSE examination, including the passing score, followed a psychometrically sound process. Self-reported time studying the FUSE curriculum predicted a passing score independent of other pretest characteristics such as years in practice and self-reported expertise.

Structured simulation improves learning of the Fundamental Use of Surgical Energy™ curriculum: a multicenter randomized controlled trial.

BACKGROUND: Energy devices can result in devastating complications to patients. Yet, they remain poorly understood by trainees and surgeons. A single-institution pilot study suggested that structured simulation improves knowledge of the safe use of electrosurgery (ES) among trainees (Madani et al. in Surg Endosc 28(10):2772-2782, 2014). The purpose of this study was to estimate the extent to which the addition of this structured bench-top simulation improves ES knowledge across multiple surgical training programs. METHODS: Trainees from 11 residency programs in Canada, the USA and UK participated in a 1-h didactic ES course, based on SAGES' Fundamental Use of Surgical Energy™ (FUSE) curriculum. They were then randomized to one of two groups: an unstructured hands-on session where trainees used ES devices (control group) or a goal-directed hands-on training session (Sim group). Pre- and post-curriculum (immediately and 3 months after) knowledge of the safe use of ES was assessed using separate examinations. Data are expressed as mean (SD) and N (%), *p < 0.05. RESULTS: A total of 289 (145 control; 144 Sim) trainees participated, with 186 (96 control; 90 Sim) completing the 3-month assessment. Baseline characteristics were similar between the two groups. Total score on the examination improved from 46% (10) to 84% (10)* for the entire cohort, with higher post-curriculum scores in the Sim group compared with controls [86% (9) vs. 83% (10)*]. All scores declined after 3 months, but remained higher in the Sim group [72% (18) vs. 64% (15)*]. Independent predictors of 3-month score included pre-curriculum score and participation in a goal-directed simulation. CONCLUSIONS: This multi-institutional study confirms that a 2-h curriculum based on the FUSE program improves surgical trainees' knowledge in the safe use of ES devices across training programs with various geographic locations and resident volumes. The addition of a structured interactive bench-top simulation component further improved learning.

Face validation of the Virtual Electrosurgery Skill Trainer (VEST©).

BACKGROUND: Electrosurgery is a modality that is widely used in surgery, whose use has resulted in injuries, OR fires and even death. The SAGES has established the FUSE program to address the knowledge gap in the proper and safe usage of electrosurgical devices. Complementing it, we have developed the Virtual Electrosurgery Skill Trainer (VEST(©)), which is designed to train subjects in both cognitive and motor skills necessary to safely operate electrosurgical devices. The objective of this study is to asses the face validity of the VEST(©) simulator. METHODS: Sixty-three subjects were recruited at the 2014 SAGES Learning Center. They all completed the monopolar electrosurgery module on the VEST(©) simulator. At the end of the study, subjects assessed the face validity with questions that were scored on a 5-point Likert scale. RESULTS: The subjects were divided into two groups; FUSE experience (n = 15) and no FUSE experience (n = 48). The median score for both the groups was 4 or higher on all questions and 5 on questions on effectiveness of VEST(©) in aiding learning electrosurgery fundamentals. Questions on using the simulator in their own skills lab and recommending it to their peers also scored at 5. Mann-Whitney U test showed no significant difference (p > 0.05) indicating a general agreement. 46% of the respondents preferred VEST compared with 52% who preferred animal model and 2% preferred both for training in electrosurgery. CONCLUSION: This study demonstrated the face validity of the VEST(©) simulator. High scores showed that the simulator was visually realistic and reproduced lifelike tissue effects and the features were adequate enough to provide high realism. The self-learning instructional material was also found to be very useful in learning the fundamentals of electrosurgery. Adding more modules would increase the applicability of the VEST(©) simulator.

Identifying Opportunities for Virtual Reality Simulation in Surgical Education: A Review of the Proceedings from the Innovation, Design, and Emerging Alliances in Surgery (IDEAS) Conference: VR Surgery.

OBJECTIVES: To conduct a review of the state of virtual reality (VR) simulation technology, to identify areas of surgical education that have the greatest potential to benefit from it, and to identify challenges to implementation. BACKGROUND DATA: Simulation is an increasingly important part of surgical training. VR is a developing platform for using simulation to teach technical skills, behavioral skills, and entire procedures to trainees and practicing surgeons worldwide. Questions exist regarding the science behind the technology and most effective usage of VR simulation. A symposium was held to address these issues. METHODS: Engineers, educators, and surgeons held a conference in November 2013 both to review the background science behind simulation technology and to create guidelines for its use in teaching and credentialing trainees and surgeons in practice. RESULTS: Several technologic challenges were identified that must be overcome in order for VR simulation to be useful in surgery. Specific areas of student, resident, and practicing surgeon training and testing that would likely benefit from VR were identified: technical skills, team training and decision-making skills, and patient safety, such as in use of electrosurgical equipment. CONCLUSIONS: VR simulation has the potential to become an essential piece of surgical education curriculum but depends heavily on the establishment of an agreed upon set of goals. Researchers and clinicians must collaborate to allocate funding toward projects that help achieve these goals. The recommendations outlined here should guide further study and implementation of VR simulation.

Percutaneous cholecystostomy versus laparoscopic cholecystectomy in patients with acute cholecystitis and failed conservative management: a matched-pair analysis.

INTRODUCTION: The role of percutaneous cholecystostomy (PC) or laparoscopic cholecystectomy (LC) in the management of patients with acute cholecystitis presenting beyond 72 hours from the onset of symptoms is unclear and undefined. The aim of this study was to examine and compare the outcomes of PC or LC in the management of these patients, who failed 24 hours of initial nonoperative management. PATIENTS AND METHODS: A retrospective chart review between January 1999 and October 2010 revealed 261 patients with acute calculus cholecystitis beyond 72 hours from onset of symptoms who failed initial nonoperative management. Twenty-three of 261 (8.8%) underwent PC and were compared with a similar 1:1 matched cohort of LC, matched using sex, age, race, BMI, diabetes, and sepsis to minimize the influence of treatment selection bias. RESULTS: There was no significant difference between PC versus LC regarding morbidity [4/23 (17%) vs. 2/23 (9%), P=0.665] and mortality [3/23 (13%) vs. 0/23 (0%), P=0.233]. The length of hospital stay was significantly longer in the PC group (15.9±12.6 vs. 7.6±4.9 d, P=0.005). CONCLUSION: In this matched cohort analysis, PC failed to show a significant reduction in morbidity compared with LC and was associated with a significantly longer hospital stay.

A comparison of NOTES transvaginal and laparoscopic cholecystectomy procedures based upon task analysis.

BACKGROUND: A virtual reality-based simulator for natural orifice translumenal endoscopic surgery (NOTES) procedures may be used for training and discovery of new tools and procedures. Our previous study (Sankaranarayanan et al. in Surg Endosc 27:1607-1616, 2013) shows that developing such a simulator for the transvaginal cholecystectomy procedure using a rigid endoscope will have the most impact on the field. However, prior to developing such a simulator, a thorough task analysis is necessary to determine the most important phases, tasks, and subtasks of this procedure. METHODS: 19 rigid endoscope transvaginal hybrid NOTES cholecystectomy procedures and 11 traditional laparoscopic procedures have been recorded and de-identified prior to analysis. Hierarchical task analysis was conducted for the rigid endoscope transvaginal NOTES cholecystectomy. A time series analysis was conducted to evaluate the performance of the transvaginal NOTES and laparoscopic cholecystectomy procedures. Finally, a comparison of electrosurgery-based errors was performed by two independent qualified personnel. RESULTS: The most time-consuming tasks for both laparoscopic and NOTES cholecystectomy are removing areolar and connective tissue surrounding the gallbladder, exposing Calot's triangle, and dissecting the gallbladder off the liver bed with electrosurgery. There is a positive correlation of performance time between the removal of areolar and connective tissue and electrosurgery dissection tasks in NOTES (r = 0.415) and laparoscopic cholecystectomy (r = 0.684) with p < 0.10. During the electrosurgery task, the NOTES procedures had fewer errors related to lack of progress in gallbladder removal. Contrarily, laparoscopic procedures had fewer errors due to the instrument being out of the camera view. CONCLUSION: A thorough task analysis and video-based quantification of NOTES cholecystectomy has identified the most time-consuming tasks. A comparison of the surgical errors during electrosurgery gallbladder dissection establishes that the NOTES procedure, while still new, is not inferior to the established laparoscopic procedure.

Effects of sleep hours and fatigue on performance in laparoscopic surgery simulators.

BACKGROUND: Studies on a virtual reality simulator have demonstrated that sleep-deprived residents make more errors. Work-hour restrictions were implemented, among other reasons, to ensure enough sleep time for residents. The objective of this study was to assess the effects of sleep time, perceived fatigue, and experience on surgical performance. We hypothesized that performance would decrease with less sleep and fatigue, and that experienced surgeons would perform better than less experienced surgeons despite sleep deprivation and fatigue. METHODS: Twenty-two surgical residents and attendings performed a peg transfer task on two simulators: the Fundamentals of Laparoscopic Skills (FLS) trainer and the Virtual Basic Laparoscopic Surgical Trainer (VBLaST©), a virtual version of the FLS. Participants also completed questionnaires to assess their fatigue level and recent sleep hours. Each subject performed ten trials on each simulator in a counterbalanced order. Performance was measured using the FLS normalized scores and analyzed using a multiple regression model. RESULTS: The multiple regression analysis showed that sleep hours and perceived fatigue were not covariates. No correlation was found between experience level and sleep hours or fatigue. Sleep hours and fatigue did not appear to affect performance. Expertise level was the only significant determinant of performance in both FLS and VBLaST©. CONCLUSIONS: Restricting resident work hours was expected to result in less fatigue and better clinical performance. In our study, peg transfer task performance was not affected by sleep hours. Experience level was a significant indicator of performance. Further examination of the complex relationship between sleep hour, fatigue, and clinical performance is needed to support the practice of work-hour restriction for surgical residents.

Laparoscopic versus open appendectomy for the obese patient: a subset analysis from a prospective, randomized, double-blind study.

BACKGROUND: The clinical outcomes for patients randomized to either open or laparoscopic appendectomy are comparable. However, it is not known whether this is true in the subset of the adult population with higher body mass indexes (BMIs). This study aimed to compare the outcomes of open versus laparoscopic appendectomy in the obese population. METHODS: A subgroup analysis of a randomized, prospective, double-blind study was conducted at a county academic medical center. Of the 217 randomized patients, 37 had a BMI of 30 kg/m(2) or higher. Open surgery was performed for 14 and laparoscopic surgery for 23 of these patients. The primary outcome measures were the postoperative complication rates. The secondary outcomes were operative time, length of hospital stay, time to resumption of diet, narcotic requirements, and Medical Outcomes Survey Short Form 36 (SF-36) quality-of-life data. RESULTS: No differences in complications between the open and laparoscopic groups were found. Also, no significant differences were seen in any of the secondary outcomes except for a longer operative time among the obese patients. CONCLUSIONS: In this study, laparoscopic appendectomy did not show a benefit over the open approach for obese patients with appendicitis.

Fibrin glue for intraperitoneal laparoscopic mesh fixation: a comparative study in a swine model.

BACKGROUND: The classic method of mesh fixation in laparoscopic ventral hernia repair is transfascial sutures with tacks. This method has been associated with low recurrence rates, but yields significant morbidity from pain and bleeding. Fibrin glue has been used successfully in inguinal hernia repair with decreased incidence of chronic pain without an increase in recurrence rates, but its utility for laparoscopic ventral hernia repair is unknown. Our aim is to evaluate the efficacy of fibrin glue for laparoscopic mesh fixation to the anterior abdominal wall compared with other fixation methods. METHODS: Four different laparoscopic mesh fixation methods were randomly assigned to midline positions along the abdominal wall of 12 female pigs and compared: (1) fibrin glue only (GO), (2) transfascial sutures with tacks (ST), (3) fibrin glue with tacks (GT), and (4) tacks only (TO). At 4 weeks post implantation, tensile strength, adhesions, migration, contraction, and buckling/folding were assessed using Kruskal-Wallis one-way analysis by ranks test. RESULTS: There were no significant differences in tensile strength, adhesions or buckling/folding among the four fixation methods. A significant increase in mean migration (3.3 vs. 0.0 mm, p = 0.03) and percentage contraction (28% vs. 14%, p = 0.02) were identified in the GO group when compared with ST (see Table 3). CONCLUSIONS: Mesh fixation using fibrin glue has comparable tensile strength and adhesion rate to sutures with tacks in the swine model. Increased contraction and migration rates associated with fibrin glue alone may be an issue and warrants further study. On the other hand, the GT group showed similar biomechanical characteristics to the other groups and may represent a reasonable alternative to the use of transfascial sutures.