Issues and Strategies in Training Left-Handed Surgeons.

Left-hand dominance in surgery is a trait historically regarded as disadvantageous to both the trainee and trainer. The aim of this editorial was to identify challenges faced by left-handed trainees and trainers across multiple surgical specialties and to propose strategies that could be implemented during surgical training. Multiple themes were identified including left-handed surgeons experiencing discrimination due to their handedness. Additionally, a higher incidence of ambidexterity among left-handed trainees was noted, suggesting that left-handed surgeons may be adapting to a lack of accommodations for left-hand trainees. Also explored were the effects of handedness in training vs practice and the effects of handedness across subspecialties including orthopedic surgery, cardiothoracic surgery, and plastic surgery. Solutions discussed involved teaching both right-handed and left-handed surgeons' ambidexterity, pairing left-handed surgeons with left-handed trainees, having left-handed instruments available, adapting the surgical environment to the operating surgeon, communicating laterality, utilizing simulation centers or virtual reality, and encouraging prospective research looking at best-practices.

Practical Strategies for Underrepresented Minority Recruitment in General Surgery Residency.

OBJECTIVE: To analyze the effects of diversification efforts on underrepresented minority in medicine (URiM) resident recruitment in general surgery residency at a single large southeastern United States academic institution with five categorical positions. METHODS: A retrospective review of applications from the 2016 to 2022 ACGME match cycles was conducted. In an effort to diversify resident recruitment, multiple new strategies were enacted in 2021. URiM candidates were identified via a more laborious review of individual applications to the program. In addition, a holistic review process was conducted, URiM faculty and residents were prominently featured, previous underperformance in diversity was openly addressed, and URiM applicants were contacted with follow up emails. Cohorts pre- and post-implementation of these strategies were analyzed. The proportion of URiM applicants invited, interviewed, ranked, and matched were compared. RESULTS: Pre-intervention during the 2016to 20 match cycles, URiM candidates represented 4% of total applicants invited. Post-intervention during the 2021to 22 match cycles, URiM candidates represented 27% of total applicants invited. Over the past 5 years under the present program director, 1 URiM resident of 24 (4%) matched into the categorical program. Over the past 15 years under the direction of 3 program directors, a total of 6 out of 69 matched residents (9%) identified as URiM. Post intervention, the program matched on average 30% of its incoming categorical class from URiM candidates. CONCLUSION: Recruitment and selection of diverse medical school applicants is an ongoing concern of general surgery residency program directors. Historically, URiM candidates are underrepresented in applicants selected for interview. Interventions aimed at increasing the matriculation of URiM include concentrated efforts to identify more URiM candidates for interview. However, importantly, transparency of ongoing diversity efforts and diversifying both faculty and trainees involved in the selection process may also improve general surgery URiM recruitment.

National Evaluation of Surgical Resident Grit and the Association With Wellness Outcomes.

Importance: Grit, defined as perseverance and passion for long-term goals, is predictive of success and performance even among high-achieving individuals. Previous studies examining the effect of grit on attrition and wellness during surgical residency are limited by low response rates or single-institution analyses. Objectives: To characterize grit among US general surgery residents and examine the association between resident grit and wellness outcomes. Design, Setting, and Participants: A cross-sectional national survey study of 7464 clinically active general surgery residents in the US was administered in conjunction with the 2018 American Board of Surgery In-Training Examination and assessed grit, burnout, thoughts of attrition, and suicidal thoughts during the previous year. Multivariable logistic regression models were constructed to assess the association of grit with resident burnout, thoughts of attrition, and suicidal thoughts. Statistical analyses were performed from June 1 to August 15, 2019. Exposures: Grit was measured using the 8-item Short Grit Scale (scores range from 1 [not at all gritty] to 5 [extremely gritty]). Main Outcomes and Measures: The primary outcome was burnout. Secondary outcomes were thoughts of attrition and suicidal thoughts within the past year. Results: Among 7464 residents (7413 [99.3%] responded; 4469 men [60.2%]) from 262 general surgery residency programs, individual grit scores ranged from 1.13 to 5.00 points (mean [SD], 3.69 [0.58] points). Mean (SD) grit scores were significantly higher in women (3.72 [0.56] points), in residents in postgraduate training year 4 or 5 (3.72 [0.58] points), and in residents who were married (3.72 [0.57] points; all P ≤ .001), although the absolute magnitude of the differences was small. In adjusted analyses, residents with higher grit scores were significantly less likely to report duty hour violations (odds ratio [OR], 0.85; 95% CI, 0.77-0.93), dissatisfaction with becoming a surgeon (OR, 0.53; 95% CI, 0.48-0.59), burnout (OR, 0.53; 95% CI, 0.49-0.58), thoughts of attrition (OR, 0.61; 95% CI, 0.55-0.67), and suicidal thoughts (OR, 0.58; 95% CI, 0.47-0.71). Grit scores were not associated with American Board of Surgery In-Training Examination performance. For individual residency programs, mean program-level grit scores ranged from 3.18 to 4.09 points (mean [SD], 3.69 [0.13] points). Conclusions and Relevance: In this national survey evaluation, higher grit scores were associated with a lower likelihood of burnout, thoughts of attrition, and suicidal thoughts among general surgery residents. Given that surgical resident grit scores are generally high and much remains unknown about how to employ grit measurement, grit is likely not an effective screening instrument to select residents; instead, institutions should ensure an organizational culture that promotes and supports trainees across this elevated range of grit scores.

Comprehensive Characterization of the General Surgery Residency Learning Environment and the Association With Resident Burnout.

OBJECTIVES: To characterize the learning environment (ie, workload, program efficiency, social support, organizational culture, meaning in work, and mistreatment) and evaluate associations with burnout in general surgery residents. BACKGROUND SUMMARY DATA: Burnout remains high among general surgery residents and has been linked to workplace exposures such as workload, discrimination, abuse, and harassment. Associations between other measures of the learning environment are poorly understood. METHODS: Following the 2019 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. The learning environment was characterized using an adapted Areas of Worklife survey instrument, and burnout was measured using an abbreviated Maslach Burnout Inventory. Associations between burnout and measures of the learning environment were assessed using multivariable logistic regression. RESULTS: Analysis included 5277 general surgery residents at 301 programs (85.6% response rate). Residents reported dissatisfaction with workload (n = 784, 14.9%), program efficiency and resources (n = 1392, 26.4%), social support and community (n = 1250, 23.7%), organizational culture and values (n = 853, 16.2%), meaning in work (n = 1253, 23.7%), and workplace mistreatment (n = 2661, 50.4%). The overall burnout rate was 43.0%, and residents were more likely to report burnout if they also identified problems with residency workload [adjusted odds ratio (aOR) 1.60, 95% confidence interval (CI) 1.31-1.94], efficiency (aOR 1.74; 95% CI 1.49-2.03), social support (aOR 1.37, 95% CI 1.15-1.64), organizational culture (aOR 1.64; 95% CI 1.39-1.93), meaning in work (aOR 1.87; 95% CI 1.56-2.25), or experienced workplace mistreatment (aOR 2.49; 95% CI 2.13-2.90). Substantial program-level variation was observed for all measures of the learning environment. CONCLUSIONS: Resident burnout is independently associated with multiple aspects of the learning environment, including workload, social support, meaning in work, and mistreatment. Efforts to help programs identify and address weaknesses in a targeted fashion may improve trainee burnout.

The Prevalence of Beers Criteria Medication Use and Associations with Falls in Geriatric Patients at a Level 1 Trauma Center.

The Beers Criteria for Potentially Inappropriate Medication (PIM) use is a list of medications with multiple risks in older patients. Approximately 24 per cent use rate is reported in prior studies. Our objective was to determine the local PIM use and subsequent fall risk in geriatric trauma patients. We conducted a retrospective analysis of PIM use in all geriatric patients evaluated at our Level 1 trauma center between 2014 and 2017. Patients were identified from our trauma database. Pre-admission medication use was determined through medication reconciliation from our electronic medical record (EMR). Patients not undergoing medication reconciliation were excluded. After initial analysis, patients were stratified by age into three groups: 65 to 74, 75 to 84, and ≥85 years. Multivariate logistic regression analyses were used to calculate odds ratios of falls for specific PIMs. In all, 2181 patients met the inclusion criteria. Overall, 71.2 per cent of geriatric trauma patients were prescribed at least one PIM-73.1 per cent of falls compared with 68.6 per cent for other mechanisms. Specific PIM use varied by age group. PIMs associated with fall risk in all patients included antipsychotics, benzodiazepines, and diclofenac. For those aged 65 to 74 years, antihistamines, diclofenac, proton pump inhibitors, and promethazine were associated. In those aged 75 to 84 years, alprazolam, antipsychotics, benzodiazepines, cyclobenzaprine, diclofenac, and muscle relaxants were implicated. No significant associations were found for patients aged ≥85 years. PIM use at our trauma center seems to be rampant and well above the national average. Geriatric falls were associated with using ≥1 PIM and multiple specific PIMs implicated. We are designing a targeted educational program for local primary care physicians (PCPs) that will attempt to decrease geriatric PIM use.

The two faces of intentional self-inflicted injury: High in-hospital mortality, low postdischarge mortality, but high readmission rates.

BACKGROUND: Intentional self-inflicted injuries present unique challenges in treatment and prevention. We hypothesized intentional self-inflicted injuries would have higher in-hospital and postdischarge mortality than nonintentional self-inflicted injuries trauma. METHODS: Adult patients evaluated 2008 to 2012 were identified in our trauma registry and matched with mortality data from the National Death Index. Intentional self-inflicted injuries were identified using E-Codes. Readmissions were identified and analyzed. Intentional self-inflicted injuries patients who died in-hospital were compared with those surviving to discharge. Univariate analysis was performed using nonparametric tests. Kaplan-Meier curves were plotted to compare mortality ≤5 years postdischarge between intentional self-inflicted injuries and non-intentional self-inflicted injuries patients. RESULTS: In the study, 8,716 patient records were evaluated with 245 (2.8%) classified as intentional self-inflicted injuries. Eighteen (7.8%) patients with intentional self-inflicted injuries had multiple admissions, compared with 352 (4.4%) patients with nonintentional self-inflicted injuries with readmissions (P = .0210). In-hospital mortality was higher for intentional self-inflicted injuries compared with patients with non-intentional self-inflicted injuries (18.7% vs 4.9%, P < .0001). Survival analysis demonstrated that patients with intentional self-inflicted injuries had significantly lower postdischarge mortality at multiple time points. CONCLUSION: Patients with intentional self-inflicted injuries trauma have high in-hospital mortality, but low postdischarge mortality. We attribute this to high lethality mechanisms but appropriate psychiatric treatment and rehabilitation. However, the high intentional self-inflicted injuries readmission rate indicates further study of intentional self-inflicted injuries follow-up is warranted. Better prevention strategies are needed to identify and intervene in patients at-risk for intentional self-inflicted injuries.

The Beers criteria: Not just for geriatrics anymore? Analysis of Beers criteria medications in nongeriatric trauma patients and their association with falls.

BACKGROUND: It has been well established that many classes of medications on the Beers list of Potentially Inappropriate Medications (PIMs) are associated with falls and injuries in the geriatric population, but little work has been performed to understand if similar relationships exist among the nongeriatric adult population. METHODS: A retrospective chart review of 32 months of trauma encounters at our Level I trauma center was performed in nongeriatric adults aged 18 years to 64 years. Encounters were reviewed by mechanism of injury and intake medication reconciliation. The data were then evaluated for associations between PIMs and falls. RESULTS: Of the 7,897 trauma encounters in the study period, 6,493 had completed medication reconciliation, and 4,154 were between the ages of 18 years and 64 years. There was a statistically significant disproportionate number of those who sustained a fall on psychoactive medications and proton pump inhibitors, and the odds of a trauma patient presenting as a fall were also significantly higher on these select classes of PIMs. CONCLUSION: The PIMs associated with falls in the geriatric population are also associated with falls in the nongeriatric population. This study supports the judicious prescribing of these medications, as they may have risks beyond what was originally thought. LEVEL OF EVIDENCE: Prognostic, level IV.

The business of educating the next generation of surgeons.

Surgical education community needs to be informed about how education is funded and how it is threatened. In order to explore these issues the Association of Surgical Education convened a panel with significant experience in managing surgery departments to discuss the business of surgical education. They specifically addressed methods to recognize and reward faculty, educate residents on safety, quality and cost, and increase departmental revenue. This information is important in the current educational environment where there is an increased need for institutions to find alternate revenue streams to sustain graduate medical education. It is also important to find additional revenue streams to fund new residency slots to accommodate the greater number medical students who have been admitted to medical schools in response to meet the projected shortage of physicians.

The Utility of Additional Imaging in Trauma Consults with Mild to Moderate Injury.

Limiting CT imaging in the ED has gained interest recently. After initial trauma workup for consultations in the ED, additional CT imaging is frequently ordered. We assessed the benefits of this additional imaging. Our hypothesis was that additional imaging in lower acuity trauma consults results in the diagnosis of new significant injuries with a change in treatment plan and increased Injury Severity Score (ISS). The registry at our Level I trauma center was queried from November 2015 to November 2016 for trauma consults initially evaluated by ED physicians. Patients with mild to moderate injuries were included. Injury findings before and after additional imaging were determined by chart review and pre- and postimaging ISS were calculated. Blinded trauma surgeons assessed the findings for clinical significance and changes in treatment. Four hundred and twenty-one patients were evaluated, 41 were excluded. One hundred and forty patients (37%) underwent additional CT imaging. Forty-seven patients (34%) had additional injuries found, with 16 (12%) increasing their ISS (mean 0.54, SD 1.66). Ninety-three per cent of cases resulted in at least one physician finding the new injuries clinically significant; however, agreement was low (κ = 0.095). For 70 per cent, at least one physician felt the findings warranted a change in treatment plan (κ = 0.405). Additional imaging in ED trauma consults resulted in the identification of new injuries in 1/3 of our patient sample. This suggests that current efforts to limit the use of CT imaging in trauma patients may result in significant injuries going undiscovered and undertreated. Further research is needed to determine the risk of attempts to limit imaging.

Relationships between study habits, burnout, and general surgery resident performance on the American Board of Surgery In-Training Examination.

BACKGROUND: The American Board of Surgery In-Training Examination (ABSITE) is used by programs to evaluate the knowledge and readiness of trainees to sit for the general surgery qualifying examination. It is often used as a tool for resident promotion and may be used by fellowship programs to evaluate candidates. Burnout has been associated with job performance and satisfaction; however, its presence and effects on surgical trainees' performance are not well studied. We sought to understand factors including burnout and study habits that may contribute to performance on the ABSITE examination. METHODS: Anonymous electronic surveys were distributed to all residents at 10 surgical residency programs (n = 326). Questions included demographics as well as study habits, career interests, residency characteristics, and burnout scores using the Oldenburg Burnout Inventory, which assesses burnout because of both exhaustion and disengagement. These surveys were then linked to the individual's 2016 ABSITE and United States Medical Licensing Examination (USMLE) step 1 and 2 scores provided by the programs to determine factors associated with successful ABSITE performance. RESULTS: In total, 48% (n = 157) of the residents completed the survey. Of those completing the survey, 48 (31%) scored in the highest ABSITE quartile (≥75th percentile) and 109 (69%) scored less than the 75th percentile. In univariate analyses, those in the highest ABSITE quartile had significantly higher USMLE step 1 and step 2 scores (P < 0.001), significantly lower burnout scores (disengagement, P < 0.01; exhaustion, P < 0.04), and held opinions that the ABSITE was important for improving their surgical knowledge (P < 0.01). They also read more frequently to prepare for the ABSITE (P < 0.001), had more disciplined study habits (P < 0.001), were more likely to study at the hospital or other public settings (e.g., library, coffee shop compared with at home; P < 0.04), and used active rather than passive study strategies (P < 0.04). Gender, marital status, having children, and debt burden had no correlation with examination success. Backward stepwise multiple regression analysis identified the following independent predictors of ABSITE scores: study location (P < 0.0001), frequency of reading (P = 0.0001), Oldenburg Burnout Inventory exhaustion (P = 0.02), and USMLE step 1 and 2 scores (P = 0.007 and 0.0001, respectively). CONCLUSIONS: Residents who perform higher on the ABSITE have a regular study schedule throughout the year, report less burnout because of exhaustion, study away from home, and have shown success in prior standardized tests. Further study is needed to determine the effects of burnout on clinical duties, career advancement, and satisfaction.

The effects of neoadjuvant therapy on morbidity and mortality of esophagectomy for esophageal cancer: American college of surgeons national surgical quality improvement program (ACS-NSQIP) 2005-2012.

OBJECTIVE: This study used a multi-center database to evaluate the impact of neoadjuvant therapy on the 30-day morbidity and mortality following esophagectomy for esophageal cancer. METHODS: The NSQIP database was queried for 2005-2012 for patients, who had esophagectomy for esophageal cancer. Patients were divided into two groups: neoadjuvant therapy and esophagectomy only. RESULTS: The neoadjuvant group had a lower rates of sepsis (8% vs. 13%, unadjusted P = 0.004) and acute renal failure (0.4% vs. 2%, unadjusted P = 0.01), and a higher rate of pulmonary embolism (PE) (3% vs. 1%, unadjusted P = 0.04). The adjusted odds of PE for patients, who received neoadjuvant therapy were 2.8 times the odds of PE for patients in the esophagectomy group, controlling for BMI. The association with renal failure was not significant, when one adjusted for race. There was no difference in the rates of reoperation, readmission, stroke, cardiac arrest, MI, surgical site and deep organ infections, anastomosis failure, blood transfusions, DVT, septic shock, pneumonia, UTI, respiratory failure, and 30-day mortality between the two groups. CONCLUSIONS: We conclude that neoadjuvant therapy followed by esophagectomy for esophageal cancer does not have a negative impact on 30-day mortality. Neoadjuvant therapy is associated with increased odds of PE. J. Surg. Oncol. 2017;115:296-300. © 2016 Wiley Periodicals, Inc.

National Surgical Quality Improvement Program integration with Morbidity and Mortality conference is essential to success in the march to zero.

BACKGROUND: Morbidity and Mortality conference (M&M) and the National Surgical Quality Improvement Program (NSQIP) are systems to improve surgical care. We evaluated the commonality of adverse events (AEs) and the change in AE rates after integration. METHODS: A single institution's NSQIP and M&M registries were analyzed to determine commonality of AE reported. Causal determinant groups were then created to categorize and standardize AE. Incidence of AE and patient commonality identified by these systems was evaluated over 2 years. RESULTS: The 68 common patients identified in 2012 represented 27% of NSQIP and 43% of M&M patients. Common AE reported by M&M and NSQIP decreased from 16.9% (2013) to 9.6% (2014). Causality code analysis demonstrated significant differences in proportion of issues addressed within each (P < .0001). CONCLUSIONS: Despite standardized coding, M&M focus differed from NSQIP. Low commonality affirms NSQIP as a critical adjunct to voluntary reporting. Combining both may help eliminate preventable AEs.

Restating Surgical Risk: From Patient to Population.

BACKGROUND: Recent federal legislation driving transition from fee-for-service to alternative methods of payment makes risk recognition essential for determination of appropriate payment systems. Because negotiations will include bundled population cohorts, we compared risk and results of an urban safety net teaching hospital's surgical population with state and national cohorts. STUDY DESIGN: Deidentified summary data for 2013 and 2014 were analyzed to compare the safety net teaching hospital with a statewide collaborative and a national cohort from similar academic centers. Incidence of preoperative risk factors were compared, identifying those that were >50% higher than both state and national experiences. These were compared for change in incidence between years. Outcomes were evaluated by 30-day mortality, readmissions, return to operating room, length of stay, and adverse events incidence. RESULTS: For both years, incidence of smoking, ventilator dependence, and CHF within 30 days was >50% higher than in the state and national cohorts. In 2014, septic shock was added to this, along with increased diabetes (14.3% to 19.8%), CHF (1.9% to 2.8%), and hypertension (39.9% to 52.5%). Despite these changes, 30-day mortality, return to operating room, length of stay, and readmissions were within ±5% of state and national results. Unplanned intubation, ventilation longer than 48 hours, and acute renal failure were 10th decile outliers. Median and interquartile range for length of stay were similar for all 3 populations across both years. CONCLUSIONS: The incidence of comorbid conditions defines greater risk in this safety net teaching hospital population. Increased smoking-related pathology reflects local population disease burden, and increased ventilator support defines additional cost for this care. As disease-, procedure-, or population-based payment alternatives evolve, risk recognition, reduction, and resolution will be essential for determination of cost-efficient, optimal, surgical outcomes.

Macro vs micro level surgical quality improvement: a regional collaborative demonstrates the case for a national NSQIP initiative.

BACKGROUND: The Florida Surgical Care Initiative (FSCI) is a quality improvement collaborative of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and the Florida Hospital Association. In the wake of a dramatic decrease in complications and cost documented over 15 months, we analyzed the semiannual measures reports (SAR) to determine whether this improvement was driven by specific institutions or was a global accomplishment by all participants. METHODS: Reports from NSQIP were analyzed to determine rank change of participants. Odds ratio (OR) of observed-to-expected incidence of the 4 FSCI outcomes (catheter-associated urinary tract infection [CAUTI], surgical site infection [SSI], colorectal, and surgery in patients older than 65 years) were used to assess individual and group performance. Data from SAR 2 (October 2011 to April 2012) were compared with data from SAR 3 (May to July 2012). Poorly performing hospitals were tracked to determine evidence of improvement. Individual facility performance was evaluated by determining proportion of hospitals showing improved rank across all measures. RESULTS: Fifty-four hospitals were evaluated. SAR 2 reported 28,112 general and vascular surgical cases; SAR 3 added 10,784 more. The proportion of institutions with OR < 1 for each measure did not change significantly. Only urinary tract infection and colorectal measures demonstrated increased number of hospitals with OR < 1. Each institution that was a significant negative outlier in SAR 2 demonstrated improvement. Three of 54 hospitals demonstrated improvement across all 4 measures. Of 15 hospitals with improved performance across 3 measures, all included elderly surgery. CONCLUSIONS: The increase in quality achieved across this population of surgical patients was the result of a quality assessment process driven by NSQIP rather than disproportionate improvement of some raising the bar for all. The NSQIP process, applied collaboratively across a population by committed institutions, produces dramatic results.

Automated analysis of electronic medical record data reflects the pathophysiology of operative complications.

PURPOSE: We hypothesized that a novel algorithm that uses data from the electronic medical record (EMR) from multiple clinical and biometric sources could provide early warning of organ dysfunction in patients with high risk for postoperative complications and sepsis. Operative patients undergoing colorectal procedures were evaluated. METHODS: The Rothman Index (RI) is a predictive model based on heuristic equations derived from 26 variables related to inpatient care. The RI integrates clinical nursing observations, bedside biometrics, and laboratory data into a continuously updated, numeric physiologic assessment, ranging from 100 (unimpaired) to -91. The RI can be displayed within the EMR as a graphic trend, with a decreasing trend reflecting physiologic dysfunction. Patients undergoing colorectal procedures between June and October 2011 were evaluated to determine correlation of initial RI, average inpatient RI, and lowest RI to incidence of complications and/or postoperative sepsis. Patients were stratified by color-coded RI risk group (100-65, blue; 64-40, yellow; <40 red). One-way or repeated-measures analysis of variance was used to compare groups by age, number of complications, and presence of sepsis defined by discharge International Classification of Diseases, 9(th) Revision, codes. Mean direct cost of care and duration of stay also was calculated for each group. RESULTS: The overall incidence of perioperative complications in the 124 patient cohort was 51% (n = 64 patients). The 261 complications sustained by this group represented 82 distinct diagnoses. The 10 patients with sepsis (8%) experienced a 40% mortality. Analysis of initial RI for the population stratified by number of complications and/or sepsis demonstrated a risk-related difference. With progressive onset of complications, the RI decreased, suggesting worsening physiologic dysfunction and linear increase in direct cost of care. CONCLUSION: These findings demonstrate that EMR data can be automatically compiled into an objective metric that reflects patient risk and changing physiologic state. The automated process of continuous update reflects a physiologic trajectory associated with evolving organ system dysfunction indicative of postoperative complications. Early intervention based on these trends may guide preoperative counseling, enhance pre-emptive management of adverse occurrences, and improve cost-efficiency of care.

Adjuvant nutrition management of patients with liver failure, including transplant.

This article reviews nutrition support in patients with liver disease, including those who are undergoing surgery or liver transplant. The topics covered include the multifactorial etiology of malnutrition, nutritional assessment, and nutritional therapy. Recommendations for use of both enteral and parenteral nutrition are given in patients with alcoholic hepatitis, cirrhosis, and acute liver failure and in patients undergoing surgery or liver transplant.

Incidental diagnosis of appendiceal mucocele with vaginal ultrasonography and computed tomography.

BACKGROUND: Appendiceal mucocele is an uncommon entity that may be encountered at the time of abdominal surgery performed for an unrelated indication. The diagnosis may be suggested by imaging with ultrasonography or computed tomography of the abdomen and pelvis. Whereas early resection is curative, failure to recognize the disorder may lead to rupture and the devastating consequences of pseudomyxoma peritonei. CASE: Following an annual gynecologic checkup in a healthy 63-year-old woman, vaginal ultrasonography along with a subsequent computed tomographic study raised the possibility that an incidental appendiceal mucocele was present. At laparoscopy, this diagnosis was confirmed and the lesion was resected using minimally invasive techniques. CONCLUSION: Early diagnosis and treatment of appendiceal mucocele facilitates the successful management of this rare disorder.

Invited lecture: American Board of Surgery Maintenance of Certification explained.

The American Board of Surgery Maintenance of Certification program requires more effort on the part of individual diplomates, but the principle is to create a better way of documenting the approach to maintenance of certification. The Maintenance of Certification program was designed to document that American Board of Surgery diplomates are maintaining the necessary competencies to provide quality care.