Factors contributing to prolonged operative time for laparoscopic cholecystectomy performed by trainee surgeons: a retrospective single-center study.

PURPOSE: Laparoscopic cholecystectomy for a benign disease is often the initial endoscopic surgery performed by trainee surgeons. However, a lack of surgical experience is associated with prolonged operative times, which may increase the risk of postoperative complications and poor outcomes. This study aimed to identify the factors associated with prolonged operative times for laparoscopic cholecystectomy performed by inexperienced surgeons. METHODS: This retrospective single-center study was conducted between January 2018 and December 2023. We performed a multivariate analysis to identify the factors associated with prolonged operative time by analyzing elective cases of laparoscopic cholecystectomy performed by surgeons with limited experience. RESULTS: The study included 323 patients, subjected to a median operative time of 89 min. Multivariate analysis identified that patient characteristics such as male sex, increased body mass index, and a history of conservative treatment for cholecystitis, as well as operating surgeon's post-graduation years (< 4 years), and an attending surgeon without endoscopic surgical skill certification from the Japan Society of Endoscopic Surgery, were independent risk factors for a prolonged operative time. CONCLUSION: Our findings suggest that endoscopic surgical skill-certified attending surgeons have excellent coaching skills and mitigate the operative time for elective cholecystectomy.

Factors prolonging the operative time for transumbilical laparoscopic-assisted appendectomy in pediatric patients: a retrospective single-center study.

PURPOSE: Transumbilical laparoscopic-assisted appendectomy (TULAA) is one of the first endoscopic surgeries performed by trainee pediatric surgeons. While the operative time is generally shorter than for conventional laparoscopic appendectomy, the indications for this procedure are unclear and many unknown factors can prolong the operative time. We conducted this study to identify the factors that may prolong the operative time for TULAA. METHODS: This retrospective, single-center study was conducted between 2015 and 2023. We performed multivariate analysis to identify the factors associated with prolonged operative time by analyzing TULAA procedures performed by trainees. RESULTS: The study included 243 patients. The median operative time was 84 min (interquartile range, 69-114 min). Multivariate analysis revealed that an increased body mass index, elevated C-reactive protein level, a history of conservative treatment for acute appendicitis, and appendix perforation, for the patient; < 6 years' experience since graduation for the operating surgeon; and lack of board certification as a supervisor from the Japanese Society of Pediatric Surgeons for the attending surgeon were independent risk factors for prolonging the operative time. CONCLUSION: Having an attending surgeon with board certification as a supervisor by the Japanese Society of Pediatric Surgeons contributes to reducing the operative time required for TULAA.

Impact of sleep deficiency on surgical performance: a prospective assessment.

STUDY OBJECTIVES: Sleep deficiency can adversely affect the performance of resident physicians, resulting in greater medical errors. However, the impact of sleep deficiency on surgical outcomes, particularly among attending surgeons, is less clear. METHODS: Sixty attending surgeons from academic and community departments of surgery or obstetrics and gynecology were studied prospectively using direct observation and self-report to explore the effect of sleep deprivation on patient safety, operating room communication, medical errors, and adverse events while operating under 2 conditions, post-call (defined as > 2 hours of nighttime clinical duties) and non-post-call. RESULTS: Each surgeon contributed up to 5 surgical procedures post-call and non-post-call, yielding 362 cases total (150 post-call and 210 non-post-call). Most common were caesarian section and herniorrhaphy. Hours of sleep on the night before the operative procedure were significantly less post-call (4.98 ± 1.41) vs non-post-call (6.68 ± 0.88, P < .01). Errors were infrequent and not related to hours of sleep or post-call status. However, Non-Technical Skills for Surgeons ratings demonstrated poorer performance while post-call for situational awareness, decision-making, and communication/teamwork. Fewer hours of sleep also were related to lower ratings for situational awareness and decision-making. Decreased self-reported alertness was observed to be associated with increased procedure time. CONCLUSIONS: Sleep deficiency in attending surgeons was not associated with greater errors during procedures performed during the next day. However, procedure time was increased, suggesting that surgeons were able to compensate for sleep loss by working more slowly. Ratings on nontechnical surgical skills were adversely affected by sleep deficiency. CITATION: Quan SF, Landrigan CP, Barger LK, et al. Impact of sleep deficiency on surgical performance: a prospective assessment. J Clin Sleep Med. 2023;19(4):673-683.

Patient Surgical Outcomes When Surgery Residents Are the Primary Surgeon by Intensity of Surgical Attending Supervision in Veterans Affairs Medical Centers.

Objective: Using health records from the Department of Veterans Affairs (VA), the largest healthcare training platform in the United States, we estimated independent associations between the intensity of attending supervision of surgical residents and 30-day postoperation patient outcomes. Background: Academic leaders do not agree on the level of autonomy from supervision to grant surgery residents to best prepare them to enter independent practice without risking patient outcomes. Methods: Secondary data came from a national, systematic 1:8 sample of n = 862,425 teaching encounters where residents were listed as primary surgeon at 122 VA medical centers from July 1, 2004, through September 30, 2019. Independent associations between whether attendings had scrubbed or not scrubbed on patient 30-day all-cause mortality, complications, and 30-day readmission were estimated using generalized linear-mixed models. Estimates were tested for any residual confounding biases, robustness to different regression models, stability over time, and validated using moderator and secondary factors analyses. Results: After accounting for potential confounding factors, residents supervised by scrubbed attendings in 733,997 nonemergency surgery encounters had fewer deaths within 30 days of the operation by 14.2% [0.3%, 29.9%], fewer case complications by 7.9% [2.0%, 14.0%], and fewer readmissions by 17.5% [11.2%, 24.2%] than had attendings not scrubbed. Over the 15 study years, scrubbed surgery attendings may have averted an estimated 13,700 deaths, 43,600 cases with complications, and 73,800 readmissions. Conclusions: VA policies on attending surgeon supervision have protected patient safety while allowing residents in selected teaching encounters to have limited autonomy from supervision.

Dual attending surgeon strategy learning curve in single-staged posterior spinal fusion (PSF) surgery for 415 idiopathic scoliosis (IS) cases.

BACKGROUND CONTEXT: The implementation of a dual attending surgeon strategy had improved perioperative outcomes of idiopathic scoliosis (IS) patients. Nevertheless, the learning curve of a dual attending surgeon practice in single-staged posterior spinal fusion (PSF) surgery has not been established. OBJECTIVE: To evaluate the surgical learning curve of a dual attending surgeon strategy in IS patients. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: 415 IS patients (Cobb angle <90°) who underwent PSF using a dual attending surgeon strategy OUTCOME MEASURES: Primary outcomes included operative time, total blood loss, allogenic blood transfusion requirement, length of hospital stay and perioperative complication rate. METHODS: Regression analysis using Locally Weighted Scatterplot Smoothing (LOWESS) method was applied to create the best-fit-curve between case number versus operative time and total blood loss in identifying cut-off points for the learning curve. RESULTS: The mean Cobb angle was 60.8±10.8°. Mean operative time was 134.4±32.1 minutes and mean total blood loss was 886.0±450.6 mL. The mean length of hospital stay was 3.0±1.6 days. The learning curves of a dual attending surgeon strategy in this study were established at the 115th case (operative time) and 196th case (total blood loss) respectively (p<.001). In comparison of cases before and after the cut-off points, mean operative time reduced significantly from 147.2±36.5 minutes to 129.5±28.9 minutes and mean total blood loss reduced significantly from 1015.1±506.6 mL to 770.4±357.3 mL (p<.001). No allogenic blood transfusion was required and there were 7 perioperative complications (n=7/415, 1.7%) recorded. CONCLUSION: The learning curve of a dual surgeon strategy in single-staged PSF surgery based on operative time and total blood loss were established at 115th case and 196th case respectively (p<.001).

Patient opinions regarding surgeon presence, trainee participation, and overlapping surgery.

OBJECTIVES: To explore patient opinions and underlying values regarding overlapping surgery (OS) scenarios, specifically evaluating the effect of attending surgeon presence and availability, as well as trainee participation on patient comfort level and willingness to consent. STUDY DESIGN: Mixed methods. METHODS: Forty adults participated in semi-structured interviews. Interviews included vignettes involving three scenarios of OS (1: attending present; 2: attending absent for wound closure; 3: attending absent and unavailable for wound closure, with covering attending), visual analog scale ratings of participants' comfort with scenarios, and cognitive debriefing. Themes and subthemes were identified using hierarchical coding of transcripts, and quantitative and qualitative analyses were conducted. RESULTS: Quantitative analysis revealed anticipated decreases in comfort with decreasing attending presence/availability (mean comfort level 94% vs. 78% vs. 63% for scenarios 1 vs. 2 vs. 3, P < 0.005), although many patients reported improved comfort with scenario 3 if meeting the covering attending. Participants demonstrated a preference for less trainee involvement (P < 0.005, scenario 1) and greater trainee experience (P < 0.05, all scenarios). However, not all individuals were uncomfortable with attending absence or trainee independence. Themes important for decision making included trust in the surgeon, surgeon experience, trainee involvement, disease severity, cost, and wait time. CONCLUSION: Patients varied highly in their willingness to consent to OS scenarios. In settings of trainee independence and covering surgeons, many patients desired meeting these members of the treatment team, which improved comfort for some. For some patients, tradeoffs and incentives of timeliness, cost, and convenience modified their willingness to have OS. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1337-1346, 2019.

Does a dual attending surgeon strategy confer additional benefit for posterior selective thoracic fusion in Lenke 1 and 2 adolescent idiopathic scoliosis (AIS)? A prospective propensity matching score analysis.

BACKGROUND CONTEXT: With an increased cost of adolescent idiopathic scoliosis (AIS) surgery over the past 10 years, improvement of patient safety and optimization of the surgical management of AIS has become an important need. A dual attending surgeon strategy resulted in reduction of blood loss and complication rate. PURPOSE: This study aimed to investigate the perioperative outcome of posterior selective thoracic fusion in Lenke 1 and 2 AIS patients comparing a single versus a dual attending surgeon strategy. STUDY DESIGN: A prospective cohort study was carried out. PATIENT SAMPLE: The study sample comprised 60 patients OUTCOME MEASURE: Operative duration, blood loss, postoperative hemoglobin, need for transfusion, morphine usage, and duration of hospital stay were the outcome measures. METHODS: A total of 116 patients who underwent posterior selective thoracic fusion from two centers were prospectively recruited. The patients were grouped into Group 1 (single surgeon) and Group 2 (two surgeons). One-to-one matching analysis using "propensity score-matched cohort patient sampling method" was done for age, gender, height, weight, preoperative Cobb angle, number of fusion level, and Lenke classification. The outcome measures included operative duration, blood loss, postoperative hemoglobin, need for transfusion, morphine usage, and duration of hospital stay. This study was self-funded with no conflict of interest. RESULTS: From 86 patients who were operated by the two surgeons (Group 2), 30 patients were matched with 30 patients who were operated by a single surgeon (Group 1). Group 2 (164.0±25.7 min) has a significantly shorter operation duration (p=.000) compared with Group 1 (257.3±51.4 min). The total blood loss was significantly more (p=.009) in Group 1 (1254.7±521.5 mL) compared with Group 2 (893.7±518.4 mL). There were seven patients (23.3%) in Group 1 who received allogenic blood transfusion (p<.05). The morphine usage and average hospital stay were significantly lower in Group 2, 22.4±10.7 mg and 3.4±0.7 days, respectively (p<.05). In Group 1, there was one patient who developed a superficial wound infection. No other major complications were noted. CONCLUSIONS: A dual attending surgeon strategy was superior to a single surgeon strategy in posterior selective thoracic fusion in Lenke 1 and 2 AIS patients and will lead to a faster operation, reduced intraoperative blood loss, reduced risk of allogenic transfusion, reduced morphine requirement, and shorter hospital stay.

Impact of the surgeon of the week system in an academic pediatric surgery practice.

BACKGROUND: A pilot rounding surgeon of the week (SOW) program was implemented in our institution on July 2013 to improve patient care through focused attending rounds. The purpose of this study was to assess the impact of the SOW. METHODS: We performed a descriptive retrospective study from a single, large-volume academic center. Data were collected from July to December 2013 (post-SOW) and compared to July to December 2012 (pre-SOW). Outcomes included patient safety (safety reports) and team productivity (billing data). We also evaluated nursing satisfaction through a 10-point Likert scale survey. RESULTS: The total number of patient safety complaints decreased after the SOW (37 pre-SOW versus 27 post-SOW). Work relative value units (wRVUs) increased by 8% while nonoperative billing increased by 15%. Twenty of the daytime nursing staff completed the survey and overall satisfaction with the SOW was 8.3. Twelve were employed prior to the SOW and, when analyzed independently, the proportion of employees satisfied with nursing to physician communication was higher after the SOW (55% pre-SOW vs. 83% post-SOW, p=0.13) as was perception of parental satisfaction (33% vs. 75%, p=0.04). CONCLUSIONS: The SOW program appears to improve patient safety as evidenced by a decrease in patient safety events. Additionally, the SOW program led to higher ancillary staffing satisfaction and perceived parental satisfaction without decreasing revenue. This study suggests that the SOW may be a beneficial program that could be considered at other large-volume institutions.

Ghost Surgery: A Frank Look at the Issue and How to Address It.

Ghost surgery occurs when a physician assistant, a surgical assistant, an RN first assistant, a resident, or another surgeon assists on or performs an operative or other invasive procedure without the patient's knowledge, regardless of whether the surgeon who obtained the consent was scrubbed in or not. This practice denies patients important information, eliminates their ability to provide informed consent, and represents an ethical issue that nurses must deal with when working with peers and patients. The American Nurses Association developed the Code of Ethics for Nurses to help guide nursing practice, and the provisions within the code embody the ethical issues that should guide nurses' practice in advocating for patients.