Consensus guidelines on the bedside assistant skills required in robotic surgery.

BACKGROUND: While bedside assistants play a critical role in many robotic operations, substantial heterogeneity remains in bedside assistant training pathways. As such, this study aimed to develop consensus guidelines for bedside assistant skills required for team members in robotic operations. METHODS: We designed a study using the Delphi process to develop consensus guidelines around bedside assistant skills. We generated an initial list of bedside assistant skills from the literature, training materials, and expert input. We selected experts for the Delphi process based on prior scholarship in the area of robotic bedside assistant education and experience facilitating robotic bedside assistant training. For each item, respondents specified which robotic team members should have the skill from a list of "basic" bedside assistants, "advanced" bedside assistants, surgeons, surgical technologists, and circulating nurses. We conducted two rounds of the Delphi process and defined 80% agreement as sufficient for consensus. RESULTS: Fourteen experts participated in two rounds of the Delphi process. By the end of the second round, the group had reached consensus on 253 of 305 items (83%). The group determined that "basic" bedside assistants should have 52 skills and that "advanced" bedside assistants should have 60 skills. The group also determined that surgeons should have 54 skills, surgical technologists should have 25 skills, and circulating nurses should have 17 skills. Experts agreed that all participants should have certain communication skills and basic knowledge of aspects of the robotic system. CONCLUSIONS: We developed consensus guidelines on the skills required during robotic surgery by bedside assistants and other team members using the Delphi process. These findings can be used to design training around bedside assistant skills and assess team members to ensure that each team member has the appropriate skills. Hospitals can also use these guidelines to standardize expectations for robotic team members.

Social determinants of health and outcome disparities in spine tumor surgery. Part 2: Neighborhood disadvantage and long-term outcomes.

OBJECTIVE: Neighborhood-level resource disadvantage has been previously shown to predict extent of resection, oncological follow-up, adjuvant treatment, and clinical trial participation for malignancies, including glioblastoma. The authors aimed to characterize the association between neighborhood disadvantage and long-term outcomes after spine tumor surgery. METHODS: The authors analyzed all patients who underwent surgery for primary or secondary (all metastatic pathologies) spine tumors at a single spinal oncology specialty center in the United States from 2015 to 2022. The Area Deprivation Index (ADI), a validated metric compositing 17 social determinants of health variables that ranges continuously from 0% (higher advantage) to 100% (higher disadvantage), was used to quantify neighborhood disadvantage. Patient addresses were matched to ADI on the basis of the census block of residence. Subsequently, the study population was dichotomized into advantaged (ADI 0%-33%) and disadvantaged (ADI 34%-100%) cohorts. The primary endpoint was functional status, as defined by Eastern Cooperative Oncology Group (ECOG) Performance Status Scale grade, with secondary endpoints including inpatient outcomes, mortality, readmissions, reoperations, and clinical research participation. Multivariable logistic, gamma log-link, and Cox regression adjusted for 14 confounders, including patient and oncological characteristics, general and tumor-related presenting severity, and treatment. RESULTS: In total, 237 patients underwent spine tumor surgery from 2015 to 2022, with an average age of 53.9 years, and 57.0% had primary tumors whereas 43.0% had secondary tumors; 55.3% (n = 131) were classified by ADI into the disadvantaged cohort. This cohort had higher rates of ambulation deficits on presentation (39.1% vs 23.5%, p = 0.015) and nonelective surgery (35.1% vs 23.6%, p = 0.030). Postoperatively, disadvantaged patients exhibited higher odds of residual tumor (OR 2.55, p = 0.026), especially for secondary tumors (OR 4.92, p = 0.045). Patients from disadvantaged neighborhoods additionally exhibited significantly higher odds of poor functional status at follow-up (OR 3.94, p = 0.002). Postoperative survival was 74.7% (mean follow-up 17.6 months), with the disadvantaged cohort experiencing significantly shorter survival (HR 1.92, p = 0.049). Moreover, this population had higher odds of readmission (OR 1.92, p = 0.046) and, for primary tumors, reoperation (OR 9.26, p = 0.005). Elective participation in prospective clinical research was lower among the disadvantaged cohort (OR 0.45, p = 0.016). CONCLUSIONS: Neighborhood disadvantage predicts higher rates of residual tumor, readmission, and reoperation, as well as poorer functional status, shorter postoperative survival, and decreased elective research participation. The ADI may be used to risk stratify spine oncology patients and guide targeted interventions to ameliorate neurosurgical disparities and to reduce barriers to research participation.

Social determinants of health and outcome disparities in spine tumor surgery. Part 1: An analysis of 6.6 million nationwide admissions.

OBJECTIVE: Earlier research has demonstrated that social determinants of health (SDoH) impact neurosurgical access and outcomes, but these trends are less characterized for spine tumors relative to intracranial tumors. The authors aimed to elucidate the association between SDoH and outcomes for a nationwide cohort of spine tumor surgery admissions. METHODS: The authors identified all admissions with a spine tumor diagnosis in the National Inpatient Sample (NIS) from 2002 to 2019. Four SDoH were analyzed: race and ethnicity, insurance, household income, and safety-net hospital (SNH) treatment. Hospitals in the top quartile of safety-net burden (in terms of percentage of patients receiving Medicaid or uninsured) were categorized as SNHs. Multivariable regression queried the association between 22 variables and 5 perioperative outcomes: mortality, discharge disposition, complications, length of stay (LOS), and hospitalization costs. Interaction term analysis with hospitalization year was used to assess longitudinal changes in outcome disparities. Finally, the authors constructed random forest machine learning models to assess the impact of SDoH variables on prognostic accuracy and to quantify the relative importance of predictors for disposition. RESULTS: Of 6,593,392 total admissions with spine tumors, 219,380 (3.3%) underwent surgery. Non-White race (OR 0.80-0.91, p < 0.001) and nonprivate insurance (OR 0.76-0.83, p < 0.001) were associated with lower odds of receiving surgery. Among surgical admissions, presenting severity, including of myelopathy and plegia, was elevated among non-White, nonprivate insurance, and low-income admissions (all p < 0.001). Black race (OR 0.70, p < 0.001), Medicare (OR 0.70, p < 0.001), Medicaid (OR 0.90, p < 0.001), and lower income (OR 0.88-0.93, all p < 0.001) were associated with decreased odds of favorable discharge disposition. Increased LOS and costs were observed among non-White (+6%-10% in LOS and +5%-9% in costs, both p < 0.001) and Medicaid (+16% in LOS and +6% in costs, both p < 0.001) admissions. SNH treatment was also associated with higher mortality (OR 1.49, p < 0.001) and complication (OR 1.20, p < 0.001) rates. From 2002 to 2019, disposition improved annually for Medicaid patients (OR 1.03 per year, p = 0.022) but worsened for Black patients (OR 0.98 per year, p = 0.046). Random forest models identified household income as the most important predictor of discharge disposition. CONCLUSIONS: For spine tumor admissions, SDoH predicted surgical intervention, presenting severity, and perioperative outcomes. Over 2 decades, disparities improved for Medicaid patients but worsened for Black patients. Finally, SDoH significantly improve prognostic accuracy for outcomes after spine tumor surgery. Further study toward ameliorating patient disparities for this population is warranted.

Vascular Anastomoses and Dissection: A Six-Part Simulation Curriculum for Surgical Residents.

Introduction: As surgical technologies grow, so too do demands on surgical trainees to master increasing numbers of skill sets. With the rise of endovascular surgery, trainees have fewer opportunities to practice open vascular techniques in the operating room. Simulation can bridge this gap. However, existing published open vascular simulation curricula are basic or based on expensive models. Methods: We iteratively developed an open vascular skills curriculum for second-year surgery residents comprising six 2-hour sessions. We refined the curriculum based on feedback from learners and faculty. The curriculum required skilled facilitators, vascular instruments, and tissue models. We evaluated the latest iteration with a survey and by assessing participants' technical skills using the Objective Structured Assessment of Technical Skills (OSATS) form. Results: Over the past 10 years, 101 residents have participated in the curriculum. Nine of 13 residents who participated in the latest curricular iteration completed the survey. All respondents rated the sessions as excellent and strongly agreed that they had improved their abilities to perform anastomoses with tissue and prosthetic. Facilitators completed 18 OSATS forms for residents in the fifth and sixth sessions of the latest iteration. Residents scored well overall, with a median 26.5 (interquartile range: 24-29) out of a possible score of 35, with highest scores on knowledge of instruments. Discussion: This simulation-based curriculum facilitates open vascular surgical skill acquisition among surgery residents. The curriculum allows residents to acquire critical vascular skills that are challenging to learn in an increasingly demanding operative setting.

An At-Home Laparoscopic Curriculum for Junior Residents in Surgery, Obstetrics/Gynecology, and Urology.

Introduction: Laparoscopic surgery requires significant training, and prior studies have shown that surgical residents lack key laparoscopic skills. Many educators have implemented simulation curricula to improve laparoscopic training. Given limited time for dedicated, in-person simulation center practice, at-home training has emerged as a possible mechanism by which to expand training and promote practice. There remains a gap in published at-home laparoscopic curricula employing embedded feedback mechanisms. Methods: We developed a nine-task at-home laparoscopic curriculum and an end-of-curriculum assessment following Kern's six-step approach. We implemented the curriculum over 4 months with first- to third-year residents. Results: Of 47 invited residents from general surgery, obstetrics/gynecology, and urology, 37 (79%) participated in the at-home curriculum, and 25 (53%) participated in the end-of-curriculum assessment. Residents who participated in the at-home curriculum completed a median of six of nine tasks (interquartile range: 3-8). Twenty-two residents (47%) responded to a postcurriculum survey. Of these, 19 (86%) reported that their laparoscopic skills improved through completion of the curriculum, and the same 19 (86%) felt that the curriculum should be continued for future residents. Residents who completed more at-home curriculum tasks scored higher on the end-of-curriculum assessment (p = .009 with adjusted R 2 of .28) and performed assessment tasks in less time (p = .004 with adjusted R 2 of .28). Discussion: This learner-centered laparoscopic curriculum provides guiding examples, spaced practice, feedback, and graduated skill development to enable junior residents to improve their laparoscopic skills in a low-stakes, at-home environment.

Streamlining the Journey of Research Into Clinical Practice: Making Your Patients and Practice Flourish Understanding and Setting Treatment Expectations for Patients With Metastatic Spine Tumors.

STUDY DESIGN: Literature review with clinical recommendation. OBJECTIVE: A concise curation of the latest spine literature exploring the relationship between expectations and satisfaction for patients with metastatic spinal disease (MSD). Deliver recommendations to practicing clinicians regarding interpretation and utilisation of this evidence. METHODS: The latest spine literature in the topic of factors affecting the expectations of patients with MSD was reviewed and clinical recommendations were formulated. Recommendations are graded as strong or Conditional. RESULTS: 5 articles were selected. Article 1: risk factors for the development of dissatisfaction from a cohort of 362 MSD patients. Strong recommendation to incorporate risk factor assessment when considering treatment. Article 2: systematic review assessing the relationship between pre-operative patient expectations and subsequent satisfaction in allied disciplines. Conditional recommendation to optimize patient expectation to positively modify patient satisfaction. Article 3: qualitative study of how clinicians, from different specialties, counsel patients with MSD pre-treatment. Strong recommendation to use a multidisciplinary approach. Article 4 qualitative study of how MSD patients experience their pre-treatment counselling and how that affected their appreciation of treatment success. Conditional recommendation to furnish patients with tailored, expected outcomes in the context of systemic progression. Article 5 Design and validation of a pre-treatment questionnaire specific to MSD. A conditional recommendation to incorporate this questionnaire in clinical and research MSD practice. CONCLUSION: Patients with MSD are approaching end of life care and high levels of treatment satisfaction are crucial at this juncture. The role of expectation management and comprehensive counselling is critical.

Comparing observed and preferred instruction in robotic surgery.

BACKGROUND: The unique setup of robotic surgery challenges the traditional instructional dynamic between surgical learners and teachers. Previous studies have posited difficulties such as reliance on observational learning and ease of takeover. However, we lack understanding of how these instructional challenges manifest and are perceived by learners. Improving instruction has the potential to optimize education and performance in robotic surgery. METHODS: In this qualitative study, we conducted robotic case observations and learner interviews focusing on instruction in robotic surgery. We deductively generated codes in a theory-informed manner after review of the instructional literature in surgery, medicine, and other fields. We applied these codes in a rigorous directed content analysis of field notes and transcripts to identify themes. RESULTS: Thirty-eight faculty, fellows, and residents participated in 10 robotic cases and 20 semistructured interviews. Observed practices on the basis of case observations differed substantially from preferred practices on the basis of interview data. Using 37 codes, we identified 4 main themes related to instruction in robotic surgery: contextualization, individualization, autonomy, and multimodality. We contrasted observed and preferred instruction in each of these areas to generate instructional considerations that may better align preferences and practices. CONCLUSIONS: We observed several suboptimal instructional practices that contradicted preferred ways of learning. We suggested robotic-specific instructional considerations such as using multimodality to promote active learning and to reduce ambiguity. We also provided considerations applicable to all types of surgery, such as to include rationale to promote learning consolidation and to frame operative steps to allow trainees to plan their participation.

Comparing Peer and Faculty Feedback for Asynchronous Laparoscopic Skill Acquisition.

OBJECTIVE: Traditionally, expert surgeons have provided surgical trainees with feedback about their simulation performance, including for asynchronous practice. Unfortunately, innumerable time demands may limit experts' ability to provide feedback. It is unknown whether and how peer feedback is an effective mechanism to help residents acquire laparoscopic skill in an asynchronous setting. As such, we aimed to assess the effect of peer feedback on laparoscopic performance and determine how residents perceive giving and receiving peer feedback. DESIGN: We conducted a convergent mixed methods study. In the quantitative component, we randomized residents to receive feedback on home laparoscopic tasks from peers or faculty. We then held an end-of-curriculum, in-person laparoscopic assessment with members from both groups and compared performance on the in-person assessment between the groups. In the qualitative component, we conducted interviews with resident participants to explore experiences with feedback and performance. Three authors coded and rigorously reviewed interview data using a directed content analysis. SETTING: We performed this study at a single tertiary academic institution: the University of California, San Francisco. PARTICIPANTS: We invited 47 junior residents in general surgery, obstetrics-gynecology, and urology to participate, of whom 37 (79%) participated in the home curriculum and 25 (53%) participated in the end-of-curriculum assessment. RESULTS: Residents in the peer feedback group scored similarly on the final assessment (mean 70.7%; SD 16.1%) as residents in the faculty feedback group (mean 71.8%; SD 11.9%) (p = 0.86). Through qualitative analysis of interviews with 13 residents, we identified key reasons for peer feedback's efficacy: shared mental models, the ability to brainstorm and appreciate new approaches, and a low-stakes learning environment. CONCLUSIONS: We found that peer and faculty feedback led to similar performance in basic laparoscopy and that residents engaged positively with peer feedback, suggesting that peer feedback can be used when residents learn basic laparoscopy.

Multidisciplinary surgical considerations for en bloc resection of sacral chordoma: review of recent advances and a contemporary single-center series.

OBJECTIVE: Contemporary management of sacral chordomas requires maximizing the potential for recurrence-free and overall survival while minimizing treatment morbidity. En bloc resection can be performed at various levels of the sacrum, with tumor location and volume ultimately dictating the necessary extent of resection and subsequent tissue reconstruction. Because tumor resection involving the upper sacrum may be quite destabilizing, other pertinent considerations relate to instrumentation and subsequent tissue reconstruction. The primary aim of this study was to survey the surgical approaches used for managing primary sacral chordoma according to location of lumbosacral spine involvement, including a narrative review of the literature and examination of the authors' institutional case series. METHODS: The authors performed a narrative review of pertinent literature regarding reconstruction and complication avoidance techniques following en bloc resection of primary sacral tumors, supplemented by a contemporary series of 11 cases from their cohort. Relevant surgical anatomy, advances in instrumentation and reconstruction techniques, intraoperative imaging and navigation, soft-tissue reconstruction, and wound complication avoidance are also discussed. RESULTS: The review of the literature identified several surgical approaches used for management of primary sacral chordoma localized to low sacral levels (mid-S2 and below), high sacral levels (involving upper S2 and above), and high sacral levels with lumbar involvement. In the contemporary case series, the majority of cases (8/11) presented as low sacral tumors that did not require instrumentation. A minority required more extensive instrumentation and reconstruction, with 2 tumors involving upper S2 and/or S1 levels and 1 tumor extending into the lower lumbar spine. En bloc resection was successfully achieved in 10 of 11 cases, with a colostomy required in 2 cases due to rectal involvement. All 11 cases underwent musculocutaneous flap wound closure by plastic surgery, with none experiencing wound complications requiring revision. CONCLUSIONS: The modern management of sacral chordoma involves a multidisciplinary team of surgeons and intraoperative technologies to minimize surgical morbidity while optimizing oncological outcomes through en bloc resection. Most cases present with lower sacral tumors not requiring instrumentation, but stabilizing instrumentation and lumbosacral reconstruction are often required in upper sacral and lumbosacral cases. Among efforts to minimize wound-related complications, musculocutaneous flap closure stands out as an evidence-based measure that may mitigate risk.

Clinical criteria for filum terminale resection in occult tethered cord syndrome.

OBJECTIVE: Tethered cord syndrome (TCS) comprises three symptom categories: back/leg pain, bowel/bladder, and neurological complaints. MRI typically reveals a low-lying conus medullaris, filum terminale (FT) pathology, or lumbosacral abnormalities. FT resection is established in TCS but not in radiologically occult TCS (OTCS). This study aims to identify patients with OTCS who are likely to benefit from FT resection. METHODS: The authors recruited 149 patients with OTCS (31 pediatric, 118 adult) treated with FT resection-including only cases with progressive TCS, negative spine MRI, and no concurrent neurological/urological conditions. A comprehensive questionnaire collected patient self-reported symptoms and clinical findings at the preoperative and at 3- and 12-month follow-up examinations. Based on questionnaire data, the authors extracted a 15-item symptoms and findings scale to represent the three TCS symptom categories, assigning 1 point for each item present. RESULTS: OTCS presents without radicular/segmental sensorimotor findings, but with leg/back pain and conus dysfunction, in addition to leg fatigue and spasticity; the latter indicating an upper motoneuron pathology. The 15-item scale showed clinical improvement in 89% of patients at the 3-month follow-up and 68% at the 12-month follow-up. Multivariate analysis of the scale revealed that it accurately predicts outcome of FT resection in 82% of cases. Patients with a preoperative score exceeding 6 points are most likely to benefit from surgery. CONCLUSIONS: By applying the study's inclusion criteria and incorporating the novel 15-item scale, surgeons can effectively select candidates for FT resection in patients with OTCS. The observed outcomes in these selected patients are comparable to those achieved in degenerative spine surgery.

Animal model considerations for chordoma research: reproducing the tumor microenvironment in vivo with humanized mice.

Animal models have been commonly used in immunotherapy research to study the cell response to external agents and to assess the effectiveness and safety of new therapies. Over the past few decades, immunocompromised (also called immunodeficient) mice allowed researchers to grow human tumor cells without the impact of the host's immune system. However, while this model is very valuable to understand the tumor biology and to understand the underlying mechanism of immunotherapy, the results may not always directly translate to humans. The tumor microenvironment has significant implications for tumor engraftment, growth, invasion, etc., and the immune system plays a critical role in shaping the tumor microenvironment. Human immunocompetent mice, also named humanized mice, are engineered mice that possess functional human immune cells. This in vivo model can be used to effectively study the effect of the human immune system to a human implanted tumor. Moreover, this can effectively mimic the response to treatment. This section is an overview of the current understanding of the different humanized mice that could be utilized to mimic the tumor microenvironment in chordoma.

Endoscopic Lateral Lumbar Interbody Fusion: Technical Note and Case Series.

BACKGROUND: Our objective is to describe a minimally invasive endoscopic surgical technique for performing lateral lumbar interbody fusion (LLIF). LLIF is a common approach to lumbar fusion in cases of degenerative lumbar disease; however, complications associated with psoas and lumbar plexus injury sometimes arise. The endoscopic modification presented here diminishes the requirement for sustained muscle retraction, minimizing complication risk while allowing for adequate decompression in select cases. METHODS: Endoscopic LLIF (ELLIF) was performed in 3 patients from 2019 to 2021. Surgeries were performed in the lateral position under general anesthesia with neurophysiological monitoring. Discectomy, endplate preparation, and harvesting of iliac crest bone were performed through a working channel endoscope. The introduction of an interbody cage (Joimax EndoLIF) was performed over a nitinol blunt-tip wire (Joimax). No expandable blade retractors were required. RESULTS: At 2-year follow-up of these 3 patients, the mean visual analog scale (VAS) score for leg pain improved from 9.3 to 1.7, and the mean Oswestry Disability Index (ODI) score improved from 40 to 8.3. There were no complications, readmissions, or recurrence of symptoms during the 2-year follow-up period. Patients spent an average of 36 hours in the hospital postoperatively and returned to normal daily activities after an average of 48 days. CONCLUSIONS: A minimally invasive modification to the LLIF procedure is presented that offers several potential advantages due to the application of endoscopic techniques: reduced muscle retraction, smaller incision, and the opportunity to perform both indirect decompression and endoscopically visualized discectomy in the same fusion procedure. CLINICAL RELEVANCE: The proposed endoscopic lateral lumbar interbody fusion and decompression is a minimally invasive technique that may provide patients with minimal complications, quick recovery, and good functional recovery.

Student challenges during third-year perioperative clerkships through the lens of faculty and residents: A qualitative study.

PURPOSE: Studies of medical students suggest they often find the transition from the pre-clinical curriculum to clinical rotations particularly challenging during perioperative clerkships. Educators could add a new perspective into students' clerkship experiences and potential interventions to improve them. The purpose of this study was to examine the educator perspective on students' experiences in perioperative clerkships. The findings could inform potential curricular interventions to facilitate student transition from a didactic environment into perioperative clerkships. METHODS: Semi-structured qualitative interviews were conducted with 16 faculty and residents in the departments of anaesthesia, obstetrics and gynaecology (OBGYN), and general surgery across multiple clinical teaching sites at one institution. Interview questions explored their perceptions of the challenges students face during their transition into perioperative clerkships and probed thoughts on curriculum interventions they believed would be the most beneficial. Interviews were recorded, transcribed and analysed thematically. FINDINGS: Three themes were identified. Faculty and residents perceive that student experiences on perioperative clerkships are shaped by (1) students' ability to adapt to the specialty and operating room norms on these clerkships, (2) students' understanding of how they can meaningfully contribute to the clinical team, and (3) dedicated teaching time constraints. Interventions were suggested to address educator expectations and student gaps, such as implementing a pre-clerkship orientation across anaesthesia, general surgery and OBGYN. CONCLUSIONS: To facilitate the medical student transition to perioperative clerkships, interventions should aid students in adapting to clerkship norms for these specialties and clarifying their role and expectations within the care team.

Disparities in Primary Spinal Osseous Malignant Bone Tumor Survival by Medicaid Status: A National Population-Based Risk Analysis.

BACKGROUND: The impact of Medicaid status on survival outcomes of patients with spinal primary malignant bone tumors (sPMBT) has not been investigated. METHODS: Using the SEER-Medicaid database, adults diagnosed between 2006 and 2013 with sPMBT including chordoma, osteosarcoma, chondrosarcoma, Ewing sarcoma, or malignant giant cell tumor (GCT) were studied. Five-year survival analysis was performed using the Kaplan-Meier method. Adjusted survival analysis was performed using Cox proportional-hazards regression controlling for age, sex, marital status, cancer stage, poverty level, vertebral versus sacral location, geography, rurality, tumor diameter, tumor grade, tumor histology, and therapy. RESULTS: A total of 572 patients with sPMBT (Medicaid: 59, non-Medicaid: 513) were identified. Medicaid patients were more likely to be younger (P < 0.001), Black (P < 0.001), live in high poverty neighborhoods (P = 0.006), have distant metastases at diagnosis (P < 0.001), and less likely to receive surgery (P = 0.006). The 5-year survival rate was 65.7% (chondrosarcoma: 70.0%, chordoma: 91.5%, Ewing sarcoma: 44.6%, GCT: 90.0%, osteosarcoma: 34.2%). Medicaid patients had significantly worse 5-year survival than non-Medicaid patients (52.0% vs. 67.2%, P = 0.02). Minority individuals on Medicaid were associated with an increased risk of cancer-specific mortality compared with White non-Medicaid patients (adjusted hazard ratio [aHR] = 2.51, [95% CI 1.18-5.35], P = 0.017). Among Medicaid patients, those who received surgery had significantly better survival than those who did not (64.5% vs. 30.6%, P = 0.001). For all patients, not receiving surgery (aHR = 1.90 [1.23-2.95], P = 0.004) and tumor diameter >50 mm (aHR=1.89 [1.10-3.25], P = 0.023) were associated with an increased risk of mortality. CONCLUSIONS: Medicaid patients may be less likely to receive surgery and suffer from poorer survival. These disparities may be especially prominent among minorities.

Overlapping worlds of art and plastic surgery: developing a concept model and its implications in surgical education.

Purpose: Editorials speculate on the relationship between art and plastic surgery, and studies of limited art education in surgical training show intriguing benefits. Identifying the shared concepts and skills in art and plastic surgery could advance incorporating artistic skills and concepts into plastic surgery training and curriculum. Methods: Using a grounded theory approach, we interviewed plastic surgeons and formally trained or self-identified artists and then analyzed the transcripts. During the process, we used a constant comparison approach while coding along with data collection. The team developed the codebook from initial transcripts; 2 members coded each transcript. We reconciled codes and summarized codes into themes based on discussion among the team. Results: 15 plastic surgeons aged 36-80 years and 16 artists aged 19-62 years were interviewed. We then developed a concept model, "Ways of Making," to illustrate the shared aspects of the artistic and surgical process through their ways of doing, knowing, seeing, and thinking. Both plastic surgeons and artists recognized that strong technical foundational skills are key to developing competency. Both groups spoke about the Elements of Art and Principles of Design, though artists know this formally. Artists and plastic surgeons shared that awareness to one's surroundings or to human features facilitates identifying problems or ideas. They described how technical skills, manual dexterity, and three-dimensional thinking can be taught and nurtured. Both groups also recognized that creativity played a major role in their work. While creativity was seen as innate, participants can learn to be innovative through critical thinking. Conclusion: This study provides a model for how plastic surgery and art overlap using data from interviews. Though there are differences between the two fields, the ways of doing, knowing, seeing, and thinking are key components of the artistic and surgical processes. Identifying the shared concepts and skills in art and plastic surgery could help enhance curricula seeking to incorporate artistic skills and concepts into plastic surgery training.

Optimizing surgical management of facet cysts of the lumbar spine: systematic review, meta-analysis, and local case series of 1251 patients.

OBJECTIVE: Lumbar facet cysts (LFCs) can cause neurological dysfunction and intractable pain. Surgery is the current standard of care for patients in whom conservative therapy fails, those with neurological deficits, and those with evidence of spinal instability. No study to date has comprehensively examined surgical outcomes comparing the multiple surgical treatment options for LFCs. Therefore, the authors aimed to perform a combined analysis of cases both in the literature and of patients at a single institution to compare the outcomes of various surgical treatment options for LFC. METHODS: The authors performed a literature review in accordance with PRISMA guidelines and meta-analysis of the PubMed, Embase, and Cochrane Library databases and reviewed all studies from database inception published until February 3, 2023. Studies that did not contain 3 or more cases, clearly specify follow-up durations longer than 6 months, or present new cases were excluded. Bias was evaluated using Cochrane Collaboration's Risk of Bias in Nonrandomised Studies-of Interventions (ROBINS-I). The authors also reviewed their own local institutional case series from 2015 to 2020. Primary outcomes were same-level cyst recurrence, same-level revision surgery, and perioperative complications. ANOVA, common and random-effects modeling, and Wald testing were used to compare treatment groups. RESULTS: A total of 1251 patients were identified from both the published literature (29 articles, n = 1143) and the authors' institution (n = 108). Patients were sorted into 5 treatment groups: open cyst resection (OCR; n = 720), tubular cyst resection (TCR; n = 166), cyst resection with arthrodesis (CRA; n = 165), endoscopic cyst resection (ECR; n = 113), and percutaneous cyst rupture (PCR; n = 87), with OCR being the analysis reference group. The PCR group had significantly lower complication rates (p = 0.004), higher recurrence rates (p < 0.001), and higher revision surgery rates (p = 0.001) compared with the OCR group. Patients receiving TCR (3.01%, p = 0.021) and CRA (0.0%, p < 0.001) had significantly lower recurrence rates compared with those undergoing OCR (6.36%). The CRA group (6.67%) also had significantly lower rates of revision surgery compared with the OCR group (11.3%, p = 0.037). CONCLUSIONS: While PCR is less invasive, it may have high rates of same-level recurrence and revision surgery. Recurrence and revision rates for modalities such as ECR were not significantly different from those of OCR. While concomitant arthrodesis is more invasive, it might lead to lower recurrence rates and lower rates of subsequent revision surgery. Given the limitations of our case series and literature review, prospective, randomized studies are needed.

Confronting new challenges: Faculty perceptions of gaps in current laparoscopic curricula in a changing training landscape.

Background: Opportunities for residents to develop laparoscopic skills have decreased with the rise in robotic operations and the development of complex, subspecialized laparoscopic operations. Given the changing training landscape, this study aimed to identify laparoscopic surgeons' perceptions of gaps in current laparoscopic skills in general surgery, obstetrics-gynecology, and urology residency programs. Methods: Laparoscopic surgeons who operate with residents participated in semi-structured interviews. Questions addressed expectations for resident proficiency, deficits in laparoscopic surgical skills, and barriers to learning and teaching. Two authors independently coded de-identified transcripts followed by a conventional content analysis. Results: Fourteen faculty members from thirteen subspecialties participated. Faculty identified three main areas to improve laparoscopic training across specialties: foundational knowledge, technical skills, and cognitive skills. They also recognized an overarching opportunity to address faculty development. Conclusions: This qualitative study highlighted key deficiencies in laparoscopic training that have emerged in the current, changing era of minimally invasive surgery. Key message: This qualitative study identified laparoscopic educators' perceptions of deficiencies in laparoscopic training. Findings emphasized the importance of incorporating high quality educational practices to optimize training in the current changing landscape of laparoscopic surgery.

Shedding light on emerging therapeutic targets for chordoma.

INTRODUCTION: Despite encouraging advances in radiation and surgical treatment, chordomas remain resistant to chemotherapy and local recurrence is common. Although the primary mechanism of recurrence is local, metastatic disease occurs in a small subset of patients. Recurrence may also occur along the surgical trajectory if care is not taken to fully excise the open biopsy pathway. There is increasing morbidity with reoperation upon disease recurrence, and radiation is an option for cytoreduction in primary disease or for recurrent disease, although toxicity may be observed with high-dose therapies. Given these challenges, targeted chemotherapeutic agents for postoperative adjuvant treatment are needed. AREAS COVERED: In this review, we summarize the genetic drivers of chordoma and the state of the current research in chordoma immunotherapy and epigenetics. EXPERT OPINION: Chordoma is a heterogenous tumor that should be targeted from different angles and the study of its characteristics, from molecular to immunological to epigenetic, is necessary. Combining different approaches, such as studying noninvasive patient methylation patterns with tissue-based molecular and drug screening, can transform patient care by guiding treatment decisions based on prognostic mechanisms from different sources, while helping individualize surgical planning and treatment.

Performance of ChatGPT and GPT-4 on Neurosurgery Written Board Examinations.

BACKGROUND AND OBJECTIVES: Interest surrounding generative large language models (LLMs) has rapidly grown. Although ChatGPT (GPT-3.5), a general LLM, has shown near-passing performance on medical student board examinations, the performance of ChatGPT or its successor GPT-4 on specialized examinations and the factors affecting accuracy remain unclear. This study aims to assess the performance of ChatGPT and GPT-4 on a 500-question mock neurosurgical written board examination. METHODS: The Self-Assessment Neurosurgery Examinations (SANS) American Board of Neurological Surgery Self-Assessment Examination 1 was used to evaluate ChatGPT and GPT-4. Questions were in single best answer, multiple-choice format. χ 2 , Fisher exact, and univariable logistic regression tests were used to assess performance differences in relation to question characteristics. RESULTS: ChatGPT (GPT-3.5) and GPT-4 achieved scores of 73.4% (95% CI: 69.3%-77.2%) and 83.4% (95% CI: 79.8%-86.5%), respectively, relative to the user average of 72.8% (95% CI: 68.6%-76.6%). Both LLMs exceeded last year's passing threshold of 69%. Although scores between ChatGPT and question bank users were equivalent ( P = .963), GPT-4 outperformed both (both P < .001). GPT-4 answered every question answered correctly by ChatGPT and 37.6% (50/133) of remaining incorrect questions correctly. Among 12 question categories, GPT-4 significantly outperformed users in each but performed comparably with ChatGPT in 3 (functional, other general, and spine) and outperformed both users and ChatGPT for tumor questions. Increased word count (odds ratio = 0.89 of answering a question correctly per +10 words) and higher-order problem-solving (odds ratio = 0.40, P = .009) were associated with lower accuracy for ChatGPT, but not for GPT-4 (both P > .005). Multimodal input was not available at the time of this study; hence, on questions with image content, ChatGPT and GPT-4 answered 49.5% and 56.8% of questions correctly based on contextual context clues alone. CONCLUSION: LLMs achieved passing scores on a mock 500-question neurosurgical written board examination, with GPT-4 significantly outperforming ChatGPT.

Home practice for robotic surgery: a randomized controlled trial of a low-cost simulation model.

Pre-operative simulated practice allows trainees to learn robotic surgery outside the operating room without risking patient safety. While simulation practice has shown efficacy, simulators are expensive and frequently inaccessible. Cruff (J Surg Educ 78(2): 379-381, 2021) described a low-cost simulation model to learn hand movements for robotic surgery. Our study evaluates whether practice with low-cost home simulation models can improve trainee performance on robotic surgery simulators. Home simulation kits were adapted from those described by Cruff (J Surg Educ 78(2): 379-381, 2021). Hand controllers were modified to mimic the master tool manipulators (MTMs) on the da Vinci Skills Simulator (dVSS). Medical students completed two da Vinci exercises: Sea Spikes 1 (SS1) and Big Dipper Needle Driving (BDND). They were subsequently assigned to either receive a home simulation kit or not. Students returned two weeks later and repeated SS1 and BDND. Overall score, economy of motion, time to completion, and penalty subtotal were collected, and analyses of covariance were performed. Semi-structured interviews assessed student perceptions of the robotic simulation experience. Thirty-three medical students entered the study. Twenty-nine completed both sessions. The difference in score improvement between the experimental and control groups was not significant. In interviews, students provided suggestions to increase fidelity and usefulness of low-cost robotic home simulation. Low-cost home simulation models did not improve student performance on dVSS after two weeks of at-home practice. Interview data highlighted areas to focus future simulation efforts. Ongoing work is necessary to develop low-cost solutions to facilitate practice for robotic surgery and foster more inclusive and accessible surgical education.