Failing Fontan cardiovascular support: Review.

BACKGROUND: Although all congenital heart defects (CHD) present unique challenges, univentricular CHD are especially challenging given the difficulty of passively perfusing pulmonary blood flow. Three surgical procedures are required within the first years of life, with the final completing a Fontan circulation in which the inferior vena cava is connected to the pulmonary artery and previously connected superior vena cava. This allows passive venous return to the pulmonary circulation then flow into the single ventricle for systemic circulation. METHODS: Although a Fontan provides successful palliation for two to three decades, many complications can arise as pulmonary resistance must remain low to allow adequate forward flow. Eventually, the failing Fontan circulation requires temporary support as the patient awaits a heart transplant. We reviewed PubMed, Google Scholar, and U. Kentucky library for different techniques evaluated to support a failing Fontan circulation. RESULTS: Multiple technologies have been developed as a bridge to transplant to decrease morbidity. Innovative types of extracorporeal membrane oxygenation, ventricular assist devices, and total artificial hearts have been attempted in laboratory settings as well as in Fontan patients with varying degrees of success. This article emphasizes the strengths and weaknesses of each technology in the context of Fontan physiology. CONCLUSION: The end game for these patients remains a heart transplant. Without easy access to donors, each of the options discussed is a potential bridge to limit morbidity and mortality until a suitable donor heart becomes available.

Readiness of US General Surgery Residents for Independent Practice.

OBJECTIVE: This study evaluates the current state of the General Surgery (GS) residency training model by investigating resident operative performance and autonomy. BACKGROUND: The American Board of Surgery has designated 132 procedures as being "Core" to the practice of GS. GS residents are expected to be able to safely and independently perform those procedures by the time they graduate. There is growing concern that not all residents achieve that standard. Lack of operative autonomy may play a role. METHODS: Attendings in 14 General Surgery programs were trained to use a) the 5-level System for Improving and Measuring Procedural Learning (SIMPL) Performance scale to assess resident readiness for independent practice and b) the 4-level Zwisch scale to assess the level of guidance (ie, autonomy) they provided to residents during specific procedures. Ratings were collected immediately after cases that involved a categorical GS resident. Data were analyzed using descriptive statistics and supplemented with Bayesian ordinal model-based estimation. RESULTS: A total of 444 attending surgeons rated 536 categorical residents after 10,130 procedures. Performance: from the first to the last year of training, the proportion of Performance ratings for Core procedures (n = 6931) at "Practice Ready" or above increased from 12.3% to 77.1%. The predicted probability that a typical trainee would be rated as Competent after performing an average Core procedure on an average complexity patient during the last week of residency training is 90.5% (95% CI: 85.7%-94%). This falls to 84.6% for more complex patients and to less than 80% for more difficult Core procedures. Autonomy: for all procedures, the proportion of Zwisch ratings indicating meaningful autonomy ("Passive Help" or "Supervision Only") increased from 15.1% to 65.7% from the first to the last year of training. For the Core procedures performed by residents in their final 6 months of training (cholecystectomy, inguinal/femoral hernia repair, appendectomy, ventral hernia repair, and partial colectomy), the proportion of Zwisch ratings (n = 357) indicating near-independence ("Supervision Only") was 33.3%. CONCLUSIONS: US General Surgery residents are not universally ready to independently perform Core procedures by the time they complete residency training. Progressive resident autonomy is also limited. It is unknown if the amount of autonomy residents do achieve is sufficient to ensure readiness for the entire spectrum of independent practice.

Hyperthermic Extracorporeal Applied Tumor Therapy for Six Cycles for Recurrent Metastatic Peritoneal Serous Papillary Carcinoma.

An elderly female with failed third-line peritoneal serous papillary carcinoma with metastasis (ovarian cancer) was treated by our proprietary method of whole-body hyperthermia-a recirculating extracorporeal circuit at 42°C for 120 minutes. She received six cycles, 28 days apart. Five index lesions were measured prior to and after each treatment. Results showed stable disease with reduced standard uptake volume. She then restarted six cycles of a previously failed chemotherapy, resulting in no evidence of disease for nine months; she survived for 27 months. Using our technology, the patient experienced an improvement in the quality of life and an increase in survival.

Prevalence and Impact of Musculoskeletal Pain Due to Operating Among Surgical Trainees.

OBJECTIVE: Upwards of 79%-88% of practicing surgeons report musculoskeletal pain due to operating. However, little is known about when these issues begin to become clinically significant. This survey evaluates the prevalence and impact of musculoskeletal pain among surgical residents. DESIGN: After IRB approval, an anonymous 19-question survey based on Cornell Musculoskeletal Discomfort Questionnaire was sent to current surgical residents measuring frequency and degree of pain at 5 sites (neck, shoulder, upper back, lower back, and elbow/wrist) as well as impact on activities both at work and outside of work. Chi square analysis was used to identify differences between groups. SETTING: Single academic medical center. PARTICIPANTS: Trainees in all surgical-based specialties. RESULTS: Fifty-three residents responded from 8 different specialties (38% response rate). Respondents were a representative balance of male (53%)/female (47%) with a mean age of 30 ± 2 years. Residents in all specialties and all years of clinical training responded, with the greatest number from general surgery (the largest program with 48% of respondents), second year of clinical training (30%) and an overwhelming 96% of residents reported experiencing pain they felt was due to operating. The most common sites of pain were the neck (92%) and lower back (77%). This pain was a frequent issue for most with 74% reporting multiple times per month and 26% reporting pain nearly every day. Nearly half of residents reported that pain slightly to substantially interfered with their ability to work (44%) and with activities outside of work (47%). Most residents (75%) sought no treatment. No residents missed work despite reporting pain. CONCLUSIONS: Musculoskeletal pain begins during training, occurs regularly, and affects function. Neck pain is the most frequent, severe, and disabling site. This provides a target for interventions to reduce the impact of chronic pain on patient care, surgeon wellness, and career longevity.

Percutaneous Cavopulmonary Assist: From Design to 96 Hour Survival in Lethal Cavopulmonary Failure Sheep.

We are developing a clinically practical percutaneous double lumen cannula (DLC)-based cavopulmonary assist (CPA) system to support failing Fontan patients. In this study, our CPA DLC was redesigned for even blood flow, minimal recirculation, and easy insertion/deployment. After bench testing, this new CPA system was evaluated for 4 hours (n = 10) and 96 hours (n = 5) in our clinically relevant lethal cavopulmonary failure (CPF) sheep model for ease of cannulation/deployment, reversal of CPF hemodynamics/end-organ hypoperfusion, and durability/biocompatibility. Cavopulmonary failure was achieved in all sheep. All DLCs were successfully inserted/deployed into Fontan anatomy. Cavopulmonary assist reversed CPF with normalized central venous pressure and cardiac output. All survival sheep were ambulatory with normal eating/drinking. One sheep was euthanized after 6 hours from cannula kinking, and one sheep died of hypokalemia after 8 hours. Three sheep survived 96 hours with normal hemodynamics. Free hemoglobin was only 3.7 ± 1.2 mg/dl at 96 hours, indicating negligible hemolysis. Creatinine, blood urea nitrogen, and lactate increased from hypoperfusion but normalized by 72 hours CPA. Necropsy showed only a small, immobilized thrombus ring at umbrella attachment to DLC. Our DLC-based system provided total ambulatory CPA in a lethal CPF sheep model with 96 hour survival and complete reversal of hemodynamics and end-organ hypoperfusion.

Implementing Workplace-Based Assessments at Scale: The SIMPL Approach.

Over the past decade, medical education has shifted from a time-based approach to a competency-based approach for surgical training. This transition presents many new systemic challenges. The Society for Improving Medical Professional Learning (SIMPL) was created to respond to these challenges through coordinated collaboration across an international network of medical educators. The primary goal of the SIMPL network was to implement a workplace-based assessment and feedback platform. To date, SIMPL has developed, implemented, and sustained a platform that represents the earliest and largest effort to support workplace-based assessment at scale. The SIMPL model for collaborative improvement demonstrates a potential approach to addressing other complex systemic problems in medical education.

Early posthospitalization recovery after extracorporeal membrane oxygenation in survivors of COVID-19.

OBJECTIVE: We sought to determine the influence of venovenous extracorporeal membrane oxygenation (ECMO) on outcomes of mechanically ventilated patients with COVID-19 during the first 120 days after hospital discharge. METHODS: Five academic centers conducted a retrospective analysis of mechanically ventilated patients with COVID-19 admitted during March through May 2020. Survivors had access to a multidisciplinary postintensive care recovery clinic. Physical, psychological, and cognitive deficits were measured using validated instruments and compared based on ECMO status. RESULTS: Two hundred sixty two mechanically ventilated patients were compared with 46 patients cannulated for venovenous ECMO. Patients receiving ECMO were younger and traveled farther but there was no significant difference in gender, race, or body mass index. ECMO patients were mechanically ventilated for longer durations (median, 26 days [interquartile range, 19.5-41 days] vs 13 days [interquartile range, 7-20 days]) and were more likely to receive inhaled pulmonary vasodilators, neuromuscular blockade, investigational COVID-19 therapies, blood transfusions, and inotropes. Patients receiving ECMO experienced greater bleeding and clotting events (P < .01). However, survival at discharge was similar (69.6% vs 70.6%). Of the 217 survivors, 65.0% had documented follow-up within 120 days. Overall, 95.5% were residing at home, 25.7% had returned to work or usual activity, and 23.1% were still using supplemental oxygen; these rates did not differ significantly based on ECMO status. Rates of physical, psychological, and cognitive deficits were similar. CONCLUSIONS: Our data suggest that COVID-19 survivors experience significant physical, psychological, and cognitive deficits following intensive care unit admission. Despite a more complex critical illness course, longer average duration of mechanical ventilation, and longer average length of stay, patients treated with venovenous ECMO had similar survival at discharge and outcomes within 120 days of discharge.

Lung transplantation in patients with coal workers' pneumoconiosis.

Patients with coal workers' pneumoconiosis (CWP) can develop chronic respiratory failure and require lung transplantation. A retrospective review was performed of the 712 referrals and 143 patients undergoing unilateral or bilateral lung transplantation at the University of Kentucky Medical Center between January 1999 and July 2009. Twenty-one of the 712 referrals (3%) had a diagnosis of CWP with eight patients eventually undergoing lung transplant (six single, two bilateral). The mean age of the cohort was 53 ± 5 (mean ± SD) yr (range 45-59). There was no increased risk of perioperative or postoperative complications. Six patients (75%) remain alive after a mean follow-up of 1013 ± 857 d with the two deaths attributable to sepsis 683 and 145 d after transplant, respectively. There were no pulmonary complications because of the native lung in patients after a single lung transplant, with otherwise good clinical outcomes seen after lung transplantation.

Using music interventions in perioperative care.

Anxiety and pain are common responses to surgery, and both can negatively affect patient outcomes. Music interventions have been suggested as a nonpharmacological intervention to alleviate pain and anxiety during surgical treatment. Although the data are somewhat mixed, the research suggests that music-based interventions are effective in reducing anxiety, pain perception, and sedative intake. The majority of studies have focused on interventions during the postoperative period and address pain reduction, with preoperative use of music targeting anxiety reduction the second most commonly cited objective. Most of the studies found in the literature involve passive music listening via headphones. The data suggest that researcher-selected music is most effective in reducing anxiety, primarily because it incorporates evidence-based parameters such as consistent tempo and dynamics, stable rhythms, and smooth melodic lines. Finally, the literature suggests that music therapists can serve as experts to help medical personnel identify effective implementation strategies.

Mobility Levels With Physical Rehabilitation Delivered During and After Extracorporeal Membrane Oxygenation: A Marker of Illness Severity or an Indication of Recovery?

OBJECTIVE: The aims of this study were to determine whether physical rehabilitation intervention for individuals who required extracorporeal membrane oxygenation (ECMO) is associated with clinical outcomes and to assess whether the patient mobility response over initial rehabilitation sessions early in the intensive care unit (ICU) course predicts or is associated with survival, lengths of stay, discharge disposition, and 30-day readmissions. METHODS: This study was a 10-year retrospective practice analysis of adults who were critically ill and required ECMO for >72 hours in the cardiothoracic ICU at an academic medical center. Physical rehabilitation implemented during or following the initiation of ECMO was quantified on the basis of timing, frequency, and change in mobility level in response to the intervention over the first 4 consecutive sessions. The primary dependent outcome was in-hospital mortality. Secondary outcomes included 30-day readmission and discharge disposition ranked on an ordinal scale. RESULTS: Three hundred fifteen individuals (mean age = 50 years [SD = 15 years]; 63% men; mean Sequential Organ Failure Assessment score = 11.6 [SD = 3.3]) met the inclusion criteria. Two hundred eighteen individuals (69%) received at least 1 physical rehabilitation session while requiring ECMO, 70 (22%) received rehabilitation after ECMO was discontinued, and 27 (9%) never received rehabilitation. Individuals discharged alive achieved higher mobility levels and had a steeper, more positive rate of change in mobility over the first 4 sessions than individuals who died in the hospital (2.8 vs 0.38; degrees of freedom = 199, t = 8.24). Those who received rehabilitation and achieved the milestones of sitting on the edge of the bed and walking for >45 m were more likely to survive (47% vs 13%; χ2 = 156) than those who did not (26% vs 3.5%; χ2 = 80). CONCLUSION: A positive rate of change in mobility and the ability to achieve mobility milestones with rehabilitation were associated with improved clinical outcomes. IMPACT: An individual's mobility response to physical rehabilitation early in the ICU course is an important indicator of illness and should be used with clinical presentation to guide clinical decision-making and predict outcomes.

Worse survival in patients with right ventricular dysfunction and COVID-19-associated acute respiratory distress requiring extracorporeal membrane oxygenation: A multicenter study from the ORACLE Group.

OBJECTIVE: We sought to determine the impact of right ventricular dysfunction on the outcomes of mechanically ventilated patients with COVID-19 requiring veno-venous extracorporeal membrane oxygenation. METHODS: Six academic centers conducted a retrospective analysis of mechanically ventilated patients with COVID-19 stratified by support with veno-venous extracorporeal membrane oxygenation during the first wave of the pandemic (March to August 2020). Echocardiograms performed for clinical indications were reviewed for right and left ventricular function. Baseline characteristics, hospitalization characteristics, and survival were compared. RESULTS: The cohort included 424 mechanically ventilated patients with COVID-19, 126 of whom were cannulated for veno-venous extracorporeal membrane oxygenation. Right ventricular dysfunction was observed in 38.1% of patients who received extracorporeal membrane oxygenation and 27.4% of patients who did not receive extracorporeal membrane oxygenation with an echocardiogram. Biventricular dysfunction was observed in 5.5% of patients who received extracorporeal membrane oxygenation. Baseline patient characteristics were similar in both the extracorporeal membrane oxygenation and non-extracorporeal membrane oxygenation cohorts stratified by the presence of right ventricular dysfunction. In the extracorporeal membrane oxygenation cohort, right ventricular dysfunction was associated with increased inotrope use (66.7% vs 24.4%, P < .001), bleeding complications (77.1% vs 53.8%, P = .015), and worse survival independent of left ventricular dysfunction (39.6% vs 64.1%, P = .012). There was no significant difference in days ventilated before extracorporeal membrane oxygenation, length of hospital stay, hours on extracorporeal membrane oxygenation, duration of mechanical ventilation, vasopressor use, inhaled pulmonary vasodilator use, infectious complications, clotting complications, or stroke. The cohort without extracorporeal membrane oxygenation cohort demonstrated no statistically significant differences in in-hospital outcomes. CONCLUSIONS: The presence of right ventricular dysfunction in patients with COVID-19-related acute respiratory distress syndrome supported with veno-venous extracorporeal membrane oxygenation was associated with increased in-hospital mortality. Additional studies are required to determine if mitigating right ventricular dysfunction in patients requiring veno-venous extracorporeal membrane oxygenation improves mortality.

A pulmonary hypertension model induced by continuous pulmonary air embolization.

BACKGROUND: Our goal was to create a clinically relevant large animal model of pulmonary hypertension to serve as a platform allowing preclinical risk/benefit assessment of innovative therapies including artificial lung prototypes. METHODS: Small amounts of filtered air were continuously infused into the pulmonary circulation of sheep (n = 4) for 8 wk. Hemodynamics and blood gases were measured daily. After termination of air embolization, the sheep were observed for 1 additional wk to assess the constancy of the pulmonary artery pressure changes. At the end of wk 9, all sheep were sacrificed and necropsy was performed. RESULTS: All animals survived the study and developed pulmonary hypertension by wk 5. Mean pulmonary artery pressures were elevated from 14 ± 1 at baseline to 35 ± 1 mmHg at wk 8 (P < 0.01) and remained unchanged throughout wk 9. A similar increase in pulmonary vascular resistance was observed. Systemic arterial pressure and PaO(2) dropped slightly compared with baselines but remained in safe ranges. Histologic evidence of severe pulmonary arterial remodeling and significant right ventricle hypertrophy was observed. CONCLUSIONS: We conclude that our 8-wk model of continuous air embolization produces reliable, chronic pulmonary hypertension in sheep with sustained hemodynamic changes, significant pulmonary vascular remodeling, and right ventricle hypertrophy.

Repair of Pulmonary Vascular Injury: A Take-Home Low-Fidelity Simulator.

We present a low-cost, simple simulation model of major vascular injury repair for cardiothoracic trainees. This model uses commercially available orthopedic elastic bands to allow repetitive practice of the skills necessary during these rare but critical clinical scenarios. Practicing core skills in the simulation setting will help residents be better prepared when the situation arises.

Ovine smoke/burn ARDS model: a new ventilator-controlled smoke delivery system.

BACKGROUND: Our current ovine smoke/burn acute respiratory distress syndrome (ARDS) model utilizes a manual bee smoker. This smoke delivery system lacks standardization and reproducibility, with 20% of sheep failing to meet ARDS criteria. Time to reach ARDS criteria and survival time are also variable. The mild volutrauma (15 mL/kg) applied after smoke/burn injury may also fail to induce ARDS within 24 h. We hypothesized that these inconsistencies were associated with the bee smoker and the mild volutrauma. In the current study, we addressed these problems to improve the consistency of the smoke/burn ARDS model. METHODS: Adult female sheep (n = 10) were given a 40% total body surface area third degree cutaneous burn and 48 breaths (4 × 12) of cotton smoke under general anesthesia. A modified ventilator was then used to deliver a precise and consistent smoke volume (tidal volume) to the sheep. Additional barotrauma was induced by pressure control ventilation (40 cm H(2)0). When ARDS criteria (PaO(2)/FiO(2) < 200) were met, the ARDS Network low tidal volume ventilation protocol (6-8 mL/kg ideal body weight) was used. RESULTS: Carboxyhemoglobin levels were 81.4% ± 5.6% immediately following smoke injury. All sheep met ARDS criteria within 24 h (12.5 ± 4.9 h). Mean survival time post-injury was 62.1 ± 26.4 h. White blood cells and granulocytes were significantly elevated at 24 h post-smoke/burn injury. Lung tissue at necropsy was consistent with ARDS. CONCLUSIONS: The refinements made to the original ovine smoke/burn ARDS model produce a more reliable time to ARDS onset, injury severity, and time of death.

Supportive Therapy: Extracorporeal Membrane Oxygenation.

Acute high-risk pulmonary embolism (PE) is characterized by life-threatening hemodynamic instability that may lead to refractory cardiac arrest. Recently, extracorporeal membrane oxygenation (ECMO) has been used to provide primary cardiopulmonary support for select high-risk PE patients or before surgical embolectomy. This article reviews the growing body of literature regarding ECMO support of acute high-risk PE.

Mitochondrial uncoupling and the disruption of the metabolic network in hepatocellular carcinoma.

BACKGROUND: Hepatocellular Carcinoma (HCC) is the third most common cause of cancer related death worldwide. Adequate treatment options for patients with advanced HCC are currently limited. MATERIALS AND METHODS: We studied the anti-HCC effect of FH535 and a novel derivative Y3, on proliferation, mitochondrial function and cellular metabolism focusing on the three key substrates, glutamine, glucose, and fatty acids. RESULTS: FH535 and Y3 disrupted mitochondrial redox control in HCC cells that resulted from uncoupling mechanisms that increased proton leakage and decreased ATP production leading to apoptosis. The uncoupling effects of the sulfonamides in HCC cells were supported by the loss of activity of the methylated analogs. The accumulation of ROS significantly contributed to cell damage after the impaired autophagic machinery. These sulfonamides, FH535 and Y3, targeted glutamine and fatty acid metabolism and caused HCC cell reprograming towards the preferential use of glucose and the glycolytic pathway. CONCLUSIONS: FH535, and Y3, demonstrated potent anti-HCC activity by targeting OXPHOS, increasing dangerous levels of ROS and reducing ATP production. These sulfonamides target glutamine and FA metabolic pathways significantly increasing the cellular dependency on glycolysis.

Detailed perioperative risk among patients with extreme obesity undergoing nonbariatric general surgery.

BACKGROUND: The obesity epidemic has spread rapidly across the United States. Although overweight and obese patients have a paradoxically lower risk for postoperative morbidity and mortality, the risks associated with extreme classes of obesity (morbid obesity, super obesity, and super-super obesity) have not been described. METHODS: We queried the National Surgical Quality Improvement Program database from 2012 to 2016. Of 1,815,251 surgical cases, there were 3,946 vascular cases, 237,777 emergency procedures, and 75,177 cases with missing data that were removed. The remaining 1,378,711 cases were included in this analysis. Multivariable linear and logistic regression was performed to assess the impact of body mass index on postoperative outcomes. RESULTS: Patients within the super obesity and super-super obesity groups had the highest procedure-adjusted mortality risk among all body mass index classes (odds ratio = 2.31 and 2.63, respectively). Morbid obesity and underweight groups had moderate risk (odds ratio = 1.37 and 1.88, respectively), while those in the overweight and obesity class I and II cohorts had improved or equivocal mortality risk compared to normal body mass index class patients. Risk-adjusted and unadjusted multivariable models demonstrated that extreme obesity classes (morbid obesity, super obesity, and super-super obesity) have a graduated escalation of perioperative morbidity, infectious, and critical care complications. CONCLUSION: Further detailing extreme obesity-related risk beyond the obesity class III umbrella is necessary for accurate risk prediction, especially with the rising prevalence of elective nonbariatric surgery in this population. Preoperative risk assessment tools should consider subgroup risk adjustment to delineate true postoperative complication risk, facilitate patient education, and address modifiable risk factors before surgery.

Trainee Autonomy in Minimally Invasive General Surgery in the United States: Establishing a National Benchmark.

OBJECTIVE: Minimally invasive surgery (MIS) is an integral component of General Surgery training and practice. Yet, little is known about how much autonomy General Surgery residents achieve in MIS procedures, and whether that amount is sufficient. This study aims to establish a contemporary benchmark for trainee autonomy in MIS procedures. We hypothesize that trainees achieve progressive autonomy, but fail to achieve meaningful autonomy in a substantial percentage of MIS procedures prior to graduation. SETTING/PARTICIPANTS: Fifty General Surgery residency programs in the United States, from September 1, 2015 to March 19, 2020. All Categorical General Surgery Residents and Attending Surgeons within these programs were eligible. DESIGN: Data were collected prospectively from attending surgeons and categorical General Surgery residents. Trainee autonomy was assessed using the 4-level Zwisch scale (Show and Tell, Active Help, Passive Help, and Supervision Only) on a smartphone application (SIMPL). MIS procedures included all laparoscopic, thoracoscopic, endoscopic, and endovascular/percutaneous procedures performed by residents during the study. Primary outcomes of interest were "meaningful autonomy" rates (i.e., scores in the top 2 categories of the Zwisch scale) by postgraduate year (PGY), and "progressive autonomy" (i.e., differences in autonomy between PGYs) in MIS procedures, as rated by attending surgeons. Primary outcomes were determined with descriptive statistics, one-way analysis of variance (ANOVA) and Z-tests. Secondary analyses compared (i) progressive autonomy between common MIS procedures, and (ii) progressive autonomy in MIS vs. non-MIS procedures. RESULTS: A total of 106,054 evaluations were performed across 50 General Surgery residency programs, of which 38,985 (37%) were for MIS procedures. Attendings performed 44,842 (42%) of all evaluations, including 16,840 (43%) of MIS evaluations, while residents performed the rest. Overall, meaningful autonomy in MIS procedures increased from 14.1% (PGY1s) to 75.9% (PGY5s), with significant (p < 0.001) increases between each PGY level. Meaningful autonomy rates were higher in the MIS vs. non-MIS group [57.2% vs. 48.0%, p < 0.001], and progressed more rapidly in MIS vs. non-MIS, (p < 0.05). The 7 most common MIS procedures accounted for 83.5% (n = 14,058) of all MIS evaluations. Among PGY5s performing these procedures, meaningful autonomy rates (%) were: laparoscopic appendectomy (95%); laparoscopic cholecystectomy (93%); diagnostic laparoscopy (87%); upper/lower endoscopy (85%); laparoscopic hernia repair (72%); laparoscopic partial colectomy (58%); and laparoscopic sleeve gastrectomy (45%). CONCLUSIONS: US General Surgery residents receive progressive autonomy in MIS procedures, and appear to progress more rapidly in MIS versus non-MIS procedures. However, residents fail to achieve meaningful autonomy in nearly 25% of MIS cases in their final year of residency, with higher rates of meaningful autonomy only achieved in a small subset of basic MIS procedures.