Comparing Outcomes of Robotic-Assisted versus Conventional Laparoscopic Hiatal Hernia Repair.

Introduction: Robotic-assisted laparoscopic surgery for anti-reflux and hiatal hernia surgery is becoming increasingly prevalent. The purpose of this study was to compare hospital length of stay and outcomes of robotic-assisted versus conventional laparoscopic hiatal hernia repair. Methods: A retrospective review was conducted of 58 patients who underwent robotic-assisted laparoscopic (n = 16, 27.6%) or conventional laparoscopic (n = 42, 72.4%) hiatal hernia repair. Results: Patient characteristics and comorbidities were similar between groups. The robotic-assisted group had a significantly higher use of fundoplication (81.3% vs. 38.1%; p = 0.007). Complications observed between the robotic-assisted and conventional laparoscopic groups were pneumothorax (6.3% vs. 11.9%; p = 1.000), infection (0% vs. 4.8%; p = 1.000), perforation (0% vs. 2.4%; p = 1.000), bleeding (6.3% vs. 2.4%; p = 0.479), ICU admission (31.3% vs. 11.9%; p = 0.119), and mechanical ventilation (18.8% vs. 2.4%; p = 0.60). There were no reported complications of dysphagia, deep vein thrombosis/pulmonary embolus, myocardial infarction, or death in either group. Hospital length of stay was similar for robotic versus conventional patients (3.0 vs. 2.5 days; p = 0.301). Conclusions: Robotic-assisted versus conventional laparoscopic hiatal hernia were compared, which demonstrated similar post-operative complication rates and hospital length of stay. The results showed robotic-assisted or conventional laparoscopic hiatal hernia repair can be performed with similar outcomes.

Chief Resident Indirect Supervision in Training Safety Study: Is a Chief Resident General Surgery Service Safe for Patients?

OBJECTIVE: There has been concern expressed amongst the medical educational community regarding the readiness of general surgery residents in the United States to be competent practicing attendings upon graduation and that limited autonomy may be a contributing factor to this unpreparedness. The purpose of this study was to evaluate an RRC-accredited general surgery residency chief resident acute care surgery service with indirect supervision of cases in terms of safety and outcomes compared to traditional general surgeon cases with direct supervision. The study focused on common general surgical procedures, specifically cholecystectomies, appendectomies, and inguinal and ventral hernia repairs. DESIGN: A retrospective review was conducted of patient data from August 2016 to June 2018 to review all patients 16 years old and older who had received one of the following procedures: appendectomy, cholecystectomy, inguinal hernia repair, or ventral hernia repair. Patient characteristics, procedure type, procedure time, estimated blood loss, complications, length of hospital stay, 30-day readmission, 30-day ED visit, need for reoperation, and mortality were compared between attending direct supervision and chief resident indirect supervision surgery services. SETTING: A single institution associated with a community based-university associated hybrid general surgery residency was included in this study. PARTICIPANTS: Patients aged 16 years or older who underwent one of the operations of interest and were discharged between the dates of August 2016 and June 2018. The operations were performed by, or indirectly supervised by, attendings who were both private surgeons and also covered the chief resident service. RESULTS: A total of 1000 cases were reviewed, with a total of 960 included in the final data after exclusions applied. Of the 960 cases included, 68.4% were traditional attending surgeon cases with direct supervision and 31.6% were chief resident service cases with indirect supervision. A total of 161 appendectomies, 396 cholecystectomies, 201 inguinal hernias and 202 ventral hernias were included. Overall, patients in the chief resident service were more often minorities (27.7 vs. 9.4%, p < 0.001), female (56.4 vs. 44.6%, p = 0.001), younger (40 vs. 55 years, p < 0.001), had a higher BMI (31.2 vs. 29.6, p = 0.018), and a lower ASA class (class 1+2 was 86.4 vs. 65.6%, p < 0.001). The median Charleson Comorbidity Index of the chief resident service patients was lower than that of the attending service (0 vs. 2, p < 0.001). Chief resident service cases were also more often urgent cases (40.6 vs. 22.8%, p < 0.001). Overall, the 30-day complication rate was similar between the two services (5.6 vs. 5.8%, p = 1.000). Complications observed from chief resident service and attending service supervised cases included pneumonia (0.3 vs. 0.5%, p = 1.000), surgical site infection (2.3 vs. 1.5%, p = 0.389), UTI (1.0 vs. 0.6%, p = 0.685), acute kidney injury (0.0 vs. 0.8%, p = 0.333), small bowel obstruction (0.0 vs. 0.6%, p = 0.314), cerebrovascular accident (0.0 vs. 0.2%, p = 1.000), and hematoma/seroma (2.3 vs. 1.7%, p = 0.500). There were no statistically significant differences in procedure-specific complications between services. There was one 30-day mortality in the study population, in the attending service group. CONCLUSIONS: This study's data suggest that a chief resident acute care surgery service with indirect supervision of cases is safe in this community with regards to appendectomies, cholecystectomies and hernia repairs.

A Pilot and Feasibility Study to Evaluate Small and Large Bite Fascial Closure Techniques.

INTRODUCTION: Few randomized controlled studies have been conducted comparing a small to large fascial bite technique, yet recommendations have been made to standardize small bite closures. However, large scale randomized controlled trials require considerable effort and may benefit from a pilot study. METHODS: This multi-center randomized controlled pilot study of adult patients undergoing median laparotomy incision investigated the feasibility of studying the outcomes between small and large surgical closure techniques. RESULTS: Fifty of 100 planned patients consented, 32 patients completed surgery, and 19 patients completed the one-year ultrasound. Enrollment was 2.7 versus 8 patients per month pre/post addition of a study coordinator. Clinical results are summarized for feasibility demonstration purposes, but not analyzed for hypothesis testing. The total cost of the pilot study was $19,152.50 and took 22 months from first surgery to final one-year ultrasound. CONCLUSIONS: This feasibility assessment demonstrated the complexity of planning a large-scale randomized trial evaluating small and large bite surgical closure technique. To expand this pilot study to a full scaled sample size study would require dedicated personnel and large grant funding.

Traumatic injuries associated with Segways and personal transporters.

Segways and other personal transporters are emerging as alternative modes of transportation that blur the distinction between pedestrian and vehicular traffic. We reviewed the records of four patients who were traumatically injured while piloting personal transporters. All required hospital admission for major blunt force trauma; three were admitted to the intensive care unit. Two intensive care unit admissions were for neurologic monitoring of severe intracranial hemorrhage. The other critically ill patient had an extensive chest wall injury and respiratory failure resulting in a tracheostomy. The fourth patient suffered an open lower extremity fracture requiring extensive reconstructive orthopedic surgery. Surgeons should be aware of the potential serious nature of associated injuries.

What Procedures Are Rural General Surgeons Performing and Are They Prepared to Perform Specialty Procedures in Practice?

Rural surgeons are performing operations typically performed by "specialists." This study describes specialty procedures performed by general surgeons operating in a rural state and how prepared the surgeons felt starting their rural practice after residency A survey was sent to all exclusively rural surgeons actively practicing in the state, inquiring about their perception of preparedness for rural practice and specialty procedures performed. The survey had a 65.2 per cent response rate. Responders felt well prepared for rural practice after residency (mean response 4.6 ± 0.8 on a Likert scale from 1 to 5; 5 = "well prepared"). Noteworthy, specialty procedures performed by rural surgeons included hysterectomies (51.2%), thyroidectomies (81.4%), parathyroidectomies (60.5%), carotid endarterectomies (11.6%), video-assisted thoracoscopic surgery (37.2%), and lobectomies (23.3%). Prominent write-ins included nephrectomies (n = 1), ileal conduits (n = 1), open and endovascular abdominal aortic aneurysm repair (n = 1), Whipples (n = 3), and liver resections (n = 2). Rural general surgeons perform many major operations usually performed by specialists. These surgeons felt well prepared for these operations out of residency.

Evaluation of general surgery residency program websites.

BACKGROUND: The purpose of this study was to evaluate the websites of general surgery residency programs in the United States and Puerto Rico. METHODS: Electronic Residency Application Service (ERAS) websites (n = 254) were accessed between October 2016 and January 2017 and evaluated for content, including: education, resident and faculty information, program environment and specific recruitment incentives. RESULTS: General information, such as conference information, rotations, and faculty information were available for more than 80% of programs. However, specific details about residents, faculty, and applicant information were noticeably lacking. This included resident biographical data and research, faculty names and research endeavors, alumni locations and fellowship placement. Applicant information, specifically board score requirements, were present in less than half of websites nationally. Regionally, websites from the Midwest were the most detailed in the information they provided, while those from the Northeast were the least informative. CONCLUSIONS: As a primary information source for potential future residents, general surgery programs need to maximize the content and utility of their websites in order to attract prospective residents to their programs.