A synopsis of the SAGES ADOPT course for foregut surgery and its positive impact on surgeons' confidence levels.

BACKGROUND: The Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program was established by SAGES to develop and expand individual surgeon's comfort with specific, complex operations using hands-on teaching and longitudinal mentoring. The 2022-2023 Foregut (Dominating the Hiatus) section of the course focused on hiatal hernia dissection and gastric fundoplication techniques. Our aim was to describe the experience of surgeons who participated in the course. METHODS: The hands-on component occurred in March 2022 at the SAGES annual meeting. Each expert mentor was matched to two participants. The mentors guided the surgeons through steps of a laparoscopic paraesophageal (PEH) hernia repair and fundoplication using a cadaveric model. Afterwards, monthly group webinars occurred and participants could receive individual coaching from their assigned mentor for a year. Each participant was given a pre-course survey with 3 and 12-month follow-up questionnaires. RESULTS: The majority of the 16 participants were employed in non-academic settings (87.5%). Years in practice ranged from 1 to 26, and 69% completed a fellowship. 100% completed the pre-course survey, and 53.8% responded to the 12-month post-course survey. Participant-reported effectiveness in performing a PEH hernia repair with fundoplication increased from 37.5% pre-course to 85.7% by the conclusion of the course. Confidence levels for the six core steps of the operation also increased: pre-course only 56-75% were confident with each step, this improved to 100% in four out of six steps. 85.7% said the course has changed their practice. DISCUSSION: Since inception, the ADOPT program has aimed to provide expert instruction for practicing surgeons to learn new techniques or improve their confidence in performing operations. The data for the 2022 ADOPT Foregut course shows that 1 year of participation made a positive impact on these surgeons' practices. This helps to fill in the learning gap that occurs after formal surgical training ends.

A cross sectional survey on burnout and career satisfaction in surgeons: a joint work from the SAGES quality, outcomes, and safety and reimaging the practice of surgery burnout task forces.

INTRODUCTION: The growth of surgeon burnout is of significant concern. As we work to reimagine the practice of surgery, an accurate understanding of the extent of surgeon burnout is essential. Our goal was to define the current prevalence of burnout and quality of life (QOL) among SAGES surgeons. METHODOLOGY: An electronic survey was administered to SAGES members to establish a current baseline for QOL, burnout, depression, and career satisfaction. To assess outcomes, we utilized the validated Maslach Burnout Inventory for Medical Personnel, the Medical Outcomes Study Short Form, and the Primary Care Evaluation of Mental Disorders. All scoring followed validated norm-based methods. RESULTS: Of 4194 active members, 604 responded (14.40%). 69% met burnout threshold, with high levels of emotional exhaustion and depersonalization, and low personal accomplishment. 81% reported "being at the end of their rope", 74% felt emotionally drained, and 65% felt used up daily. Nearly all maintained caring about what happened to their patients (96%), easily understanding how their patients feel (84.3%) and being capable of dealing effectively with their patient's problems (87.6%). However, respondents never, rarely, or occasionally felt energetic (77.5%) or experienced a sense of professional accomplishment (57.8%). The overall QOL score was 69/100, with lower Mental than Physical scores (62.69 (SD 10.20) vs.77.27 (SD 22.24)). More than half of respondents met depression criteria. While 77% supported they would become a physician again, less than half would choose surgery again or recommend surgery to their children. Furthermore, less than a third felt work allowed sufficient time for their personal lives. CONCLUSIONS: Participating SAGES surgeons reported alarmingly high rates of burnout and depression. Despite experiencing emotional exhaustion and depersonalization, they maintained a strong commitment to patient care. These findings likely reflect the broader state of surgeons, underscoring the urgent need for action to address this critical issue.

Application of the acquisition of data for outcomes and procedure transfer (ADOPT) method to a hands-on course for teaching extended-view totally extraperitoneal (eTEP) hernia repair to practicing surgeons.

BACKGROUND: After completion of training, practicing surgeons rely on hands-on courses to expand their procedure armamentarium and improve their surgical technique. However, such courses vary in standardized teaching methods. SAGES developed the Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program as a method of longitudinal instruction utilizing standardized teaching techniques, mentorship, and webinars to cover additional techniques. This study examines the adoption of learned techniques and participant confidence before and after an ADOPT course focused on extended-view totally extraperitoneal (eTEP) hernia repair. METHODS: A hands-on course focused on eTEP hernia repair was conducted with enrollment capped at 10 participants. Pre-course and post-course surveys at 3, 6, and 12 months determined implementation of the learned procedure, case volume, and confidence with eTEP skills. A 5-point Likert scale (1 = not confident at all to 5 = completely confident) assessed confidence levels. Survey responses were summarized using descriptive statistics. RESULTS: Of the 10 participants, 10 (100%) completed the pre-course survey, and 7 (70%) completed at least one post-course survey. Median age was 48.5 years (36,56) with a median of 16 years (2,23) in practice, mostly in the community setting (70%). After the course, 50% had performed an eTEP procedure, and 100% reported considering this technique during surgical planning. Participants reported higher confidence in eTEP-specific skills at three months post-course from pre-course levels. The highest change in confidence was seen for the following skills: accessing the retromuscular/extraperitoneal space for ventral hernia and recognizing when the linea alba has been violated, p < 0.05. CONCLUSION: This study shows that rapid incorporation of learned techniques can be achieved through the ADOPT format. Furthermore, through longitudinal mentorship and a structured hands-on course, the ADOPT course supports practicing surgeons to attain autonomy and confidence even when teaching a relatively technically challenging procedure, such as eTEP.

Predictive factors for operative intervention and ideal length of non-operative trial in adhesive small bowel obstruction.

BACKGROUND: Small bowel obstruction (SBO) is responsible for 350,000 U.S. hospitalizations and costs ~ $2.3 billion annually. The current standard of care for SBO is to trial 3 to 5 days of non-operative management. This study evaluated the factors associated with operative management. METHODS: This retrospective cohort study included adult patients admitted with adhesive SBO. Exclusions were for operative intervention within 24 h or death. RESULTS: At baseline (N = 360), mean age was 65.9 years, 57.8% female, 72.3% white, mean BMI 26.1, 38.7% with history of SBO and 98.1% had history of abdominal surgery. Symptom onset prior to hospitalization was 1-2 days. 55.6% had successful non-operative management at discharge (median length of stay 3 days) vs. 44.4% operative conversion. In univariate analyses, BMI, SBO history, surgical history, days symptom onset, vitals, abdominal pain, obstipation, acute kidney injury, and lack of small bowel feces sign on CT scan were significantly associated with operative management. In a multivariable logistic regression, after controlling all other variables, a lack of small bowel feces sign (adjusted odds ratio, aOR = 2.25, 95% CI 1.06-4.77, p = 0.04) and history of exploratory laparotomy (aOR = 0.44, 95% CI 0.21-0.90, p = 0.03) were significantly associated with operative management. Time from admission to surgery averaged 3.89 days: small bowel resection (55/160) was 4.9 days (median = 4), compared to patients without resection (3.4 days, median = 2; p = 0.00; OR = 1.2, 95% CI 1.07-1.35). CONCLUSIONS: A lack of small bowel feces sign can be a potential indicator for operative management and should be further explored. Since the median resolution of symptoms in the non-operative management group was ~ 2 days and a 20% higher odds for bowel resection each day surgery is delayed, the conservative trial period for adhesive SBO should not exceed 3 days.

Better than the real thing? Success of a virtual platform for an established "Train the Trainer" course.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) uses the Laparoscopic colectomy Train the Trainer (Lapco TT) framework for standardization of instructor training for Hands-On surgical skills courses. The curriculum focuses on teaching structure, skills deconstruction, trainer intervention framework, and performance enhancing feedback. A halt in the in-person Lapco TT courses due to the Coronavirus Disease 2019 (COVID-19) pandemic necessitated creation of a virtual alternative. We investigated the effectiveness of this virtual course. METHODS: Adaptation of the in-person Lapco TT course to the virtual format retained the majority of content as well as the 4:6 instructor-to-participant ratio. The virtual platform and simulators chosen allowed maximal interactivity and ease of use. After participating in the day and one half course, participants completed an 8-item post-course survey using a 5-point Likert scale related to the training experience. In addition, they had the opportunity to provide answers to several open-ended questions regarding the course. For the survey, frequency counts provided an assessment of each item. For the open questions, qualitative analysis included determination of themes for each question. Frequency counts of each theme provided quantitative analysis. RESULTS: Thirty-six total participants completed a Lapco TT virtual course (six sessions of six participants). Of this number, 32 participants completed post-course surveys and questions. All the participants completing the survey would very likely or definitely (Likert scale 4, 5) recommend the course to a colleague and incorporate the teaching in their practice. The majority of participants completing open-ended questions felt the virtual course format was effective; half thought that post-course follow-up would be useful. Technical concerns were an issue using the virtual format. CONCLUSION: A virtual Lapco TT course is feasible and well received by participants. It presents a potentially more cost effective option to faculty development.

SAGES Reimagining Education & Learning (REAL) project.

BACKGROUND: The COVID-19 pandemic has presented multiple challenges for health systems throughout the world. The clinical priorities of redirecting personnel and resources to provide the necessary beds, care, and staff to handle the initial waves of infected individuals, and the drive to develop an effective vaccine, were the most visible and rightly took precedent. However, the spread of the COVID-19 virus also led to less apparent but equally challenging impediments for healthcare professionals. Continuing professional development (CPD) for physicians and surgeons practically ceased as national societies postponed or canceled annual meetings and activities. The traditional in-person conferences were no longer viable options during a pandemic in which social distancing and minimization of contacts was the emerging norm. Like other organizations, The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) had to first postpone and then cancel altogether the in-person 2020 Annual Meeting due to the contingencies brought about by the COVID-19 pandemic. As a result, the traditional hands-on (HO) courses that typically occur as part of the Annual Meeting, could not take place. SAGES had already begun to re-structure these courses in an effort to increase their effectiveness (Dort, Trickey, Paige, Schwarz, Dunkin in Surg Endosc 33(9):3062-3068, 2019; Dort et al. in Surg Endosc 32(11):4491-4497, 2018; Dort, Trickey, Schwarz, Paige in Surg Endosc 33(9):3062-3068, 2019). The cancelations brought about by COVID-19 provided an opportunity to refine and to innovate further. METHODS: In this manner, the Re-imaging Education & Learning (REAL) project crystallized, an innovative effort to leverage the latest educational concepts as well as communication and simulation-based technologies to enhance procedural adoption by converting HO courses to a virtual format. RESULTS AND CONCLUSION: This manuscript describes the key components of REAL, reviewing the restructuring of the HO courses before and after the spread of COVID-19, describing the educational framework underlying it, discussing currently available technologies and materials, and evaluating the advantages of such a format.

SAGES 2022 guidelines regarding the use of laparoscopy in the era of COVID-19.

BACKGROUND: SARS-CoV-2 has changed global healthcare since the pandemic began in 2020. The safety of minimally invasive surgery (MIS) utilizing insufflation from the standpoint of safety to the operating room personnel is currently being explored. The aims of this guideline are to examine the existing evidence to provide guidance regarding MIS for the patient with, or suspecting of having, the SARS-CoV-2 as well as the healthcare team involved. METHODS: Systematic literature reviews were conducted for 2 key questions (KQ) regarding the safety of MIS in the setting of COVID-19 pandemic. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis criteria. Evidence-based recommendations were formulated using a narrative synthesis of the literature by subject experts. Recommendations for future research were also proposed. RESULTS: In KQ1, a total of 1361 articles were reviewed, with 2 articles meeting inclusion. In KQ2, a total of 977 articles were reviewed, with 4 articles met inclusions criteria, of which 2 studies reported on the SARS-CoV2 virus specifically. Despite many publications in the field, very little well-controlled and unbiased data exist to inform the recommendations. Of that which is available, it shows that both laparoscopic and open operations in Covid-positive patients had similar rates of OR staff positivity rates; however, patients who underwent laparoscopic procedures had a lower perioperative mortality than open procedures. Also, SARS-CoV-2 particles have been detected in the surgical plume at laparoscopy. CONCLUSION: With demonstrated equivalence of operating room staff exposure, and noninferiority of laparoscopic access with respect to mortality, either laparoscopic or open approaches to abdominal operations may be used in patients with SARS-CoV-2. Measures should be employed for all laparoscopic or open cases to prevent exposure of operating room staff to the surgical plume, as virus can be present in this plume.

At-home hands-on surgical training during COVID19: proof of concept using a virtual telementoring platform.

INTRODUCTION: Surgeons in practice have limited opportunities to learn new techniques and procedures. Traditionally, in-person hands-on courses have been the most common means for surgeons to gain exposure to new techniques and procedures. The COVID19 pandemic caused a cessation in these courses and left surgeons with limited opportunities to continue their professional development. Thus, SAGES elected to create an innovative hands-on course that could be completed at home in order to provide surgeons with opportunities to learn new procedures during the pandemic. METHODS: This course was initially planned to be taught as an in-person hands-on course utilizing the Acquisition of Data for Outcomes and Procedure Transfer(ADOPT) method 1. We identified a virtual telementoring platform, Proximie Ltd(London, UK), and a company that could create a model of an abdominal wall in order to perform a Transversus Abdominis Release, KindHeart™(Chapel Hill, NC, USA). The course consisted of pre-course lectures and videos to be reviewed by participants, a pre-course call to set learning goals, the hands-on telementoring session from home, and monthly webinars for a year. RESULTS: The ADOPT hands-on hernia course at home was successfully completed on October 23rd of 2020. All participants and faculty were successfully able to set up their model and utilize the telementoring platform, but 15% required assistance. Post course-surveys showed that participants felt that the course was successful in meeting their educational goals and felt similar to prior in-person courses. CONCLUSIONS: SAGES was successfully able to transition and in-person hands-on course to a virtual at-home format. This innovative approach to continuing professional development will be necessary during the times of the COVID19 pandemic, but may be a helpful option for rural surgeons and others with travel restrictions in the future to continue their professional development without the need to travel away from their practice.

Clinical factors associated with success in applying laparoscopy in the management of small bowel obstruction at a tertiary care center.

BACKGROUND: Minimally invasive techniques have become standard approaches for many common surgical problems. However, the routine use of laparoscopy in the management of small bowel obstruction (SBO) has yet to be fully standardized. The objective of this study was to determine clinical factors associated with success of laparoscopy in managing SBO. METHODS: A retrospective cohort study was conducted by identifying all patients admitted to a large tertiary center with a diagnosis of SBO from 2014 to 2016. The operative cases were stratified by surgical approach: laparoscopy, laparoscopy converted to open, or laparotomy. Univariable analysis compared patient demographics and comorbidities between the laparoscopic and laparoscopic converted to open group. The primary outcome was successful laparoscopic procedure in the management of SBO, defined as resolution of SBO, and no conversion from laparoscopic to open procedures. Student's t test or Pearson's χ2 test were used to assess associations between factors and primary outcome. RESULTS: A total of 227 adult patients admitted with a diagnosis of SBO received operative intervention. There were 40 successful laparoscopic cases (52.6%) and 36 failed laparoscopic cases (47.4%). With the exception of an association between success of laparoscopy and BMI, the results demonstrated no other demographic or clinical differences among the successful versus failed laparoscopic groups. CONCLUSIONS: Laparoscopy is effective in treating SBOs due to various etiologies including single band or multiple adhesions, hernias, or masses. Other than BMI, there was no single predictor of success or failure with laparoscopy. Therefore, we conclude that perhaps all patients requiring operative treatment for SBO deserve consideration for a diagnostic laparoscopy.

SAGES primer for taking care of yourself during and after the COVID-19 crisis.

COVID-19 is a pandemic which has affected almost every aspect of our life since starting globally in November 2019. Given the rapidity of spread and inadequate time to prepare for record numbers of sick patients, our surgical community faces an unforeseen challenge. SAGES is committed to the protection and care of patients, their surgeons and staff, and all who are served by the medical community at large. This includes physical health, mental health, and well-being of all involved. The fear of the unknown ahead can be paralyzing. International news media have chronicled the unthinkable situations that physicians and other health care providers have been thrust into as a result of the COVID-19 pandemic. These situations include making life or death decisions for patients and their families regarding use of limited health care resources. It includes caring for patients with quickly deteriorating conditions and limited treatments available. Until recently, these situations seemed far from home, and now they are in our own hospitals. As the pandemic broadened its reach, the reality that we as surgeons may be joining the front line is real. It may be happening to you now; it may be on the horizon in the coming weeks. In this context, SAGES put together this document addressing concerns on clinician stressors in these times of uncertainty. We chose to focus on the emotional toll of the situation on the clinician, protecting vulnerable persons, reckoning with social isolation, and promoting wellness during this crisis. At the same time, the last part of this document deals with the "light at the end of the tunnel," discussing potential opportunities, lessons learned, and the positives that can come out of this crisis.

SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic.

The unprecedented pandemic of COVID-19 has impacted many lives and affects the whole healthcare systems globally. In addition to the considerable workload challenges, surgeons are faced with a number of uncertainties regarding their own safety, practice, and overall patient care. This guide has been drafted at short notice to advise on specific issues related to surgical service provision and the safety of minimally invasive surgery during the COVID-19 pandemic. Although laparoscopy can theoretically lead to aerosolization of blood borne viruses, there is no evidence available to confirm this is the case with COVID-19. The ultimate decision on the approach should be made after considering the proven benefits of laparoscopic techniques versus the potential theoretical risks of aerosolization. Nevertheless, erring on the side of safety would warrant treating the coronavirus as exhibiting similar aerosolization properties and all members of the OR staff should use personal protective equipment (PPE) in all surgical procedures during the pandemic regardless of known or suspected COVID status. Pneumoperitoneum should be safely evacuated via a filtration system before closure, trocar removal, specimen extraction, or conversion to open. All emergent endoscopic procedures performed during the pandemic should be considered as high risk and PPE must be used by all endoscopy staff.

Something for everyone: the benefits of longitudinal mentorship with the application of the acquisition of data for outcomes and procedure transfer (ADOPT) program to a SAGES hands-on colectomy course.

Continued professional development of surgeons remains a challenging and unstandardized enterprise. The Continuing Education Committee of SAGES created the Acquisition of Data for Outcomes and Procedure Adoption (ADOPT) program, incorporating a standardized training approach into hands-on courses with a year-long longitudinal mentorship experience. To evaluate the program's transferability to other procedures following its successful application to a SAGES hernia course, the ADOPT method was applied to the SAGES 2017 laparoscopic colectomy course. Participant data included demographics, training and experience, as well as pre-and post-course self-reported colectomy case volumes and procedure confidence. Confidence levels were for techniques taught in the course using a 5-point scale: 1 = not confident at all to 5 = completely confident. Participants reported confidence in the following skills for laparoscopic right and left colectomy: (1) formulating an operative plan, (2) identifying proper anatomical planes and isolating anatomic structures, and (3) competently conducting the technical steps of the procedure. A total of 18 surgeons enrolled in the SAGES 2017 Colon Program, 10 of whom completed the 6-month post-course questionnaire (56%). Participants reported significantly higher confidence in all skills at 6 months compared to pre-course (p ≤ 0.015). Most participants (60%) reported an increase in the number of procedures performed. The lowest pre-course case volume group (≤ 5 annual cases, n = 5 6-month survey responders) demonstrated a trend for increased procedure volume post-course (5.6 vs. 2, p = 0.057). The overwhelming majority of survey respondents (90%) felt either "confident" or "extremely confident" performing the procedures learned (range 80-100% across tasks). Participants found the program to be an advantageous method of becoming competent and confident in performing these procedures. The application of the ADOPT program to the laparoscopic colectomy course was successful in increasing surgeon confidence and demonstrated a trend in improving surgeon procedure counts in the novice participant group.

Developing minimally invasive procedure quality metrics: one step at a time.

BACKGROUND: Despite extensive first-hand surgical experience, rank and file members of surgical societies are generally not trained in and have not therefore been included in surgical quality measure development. The purpose of this exercise was to determine if a structured quality metric design tool could bridge this gap, facilitating rapid development of focused quality metrics by minimally invasive surgeon attendees of the April 2018 SAGES Annual Meeting. METHODS: Expert minimally invasive surgeons attended a 90-min workshop with didactic and interactive quality metric design sessions during the Annual Meeting. The interactive portion was formed around a novel structured quality measure development tool that graded presenting symptoms, short-term complications, and long-term disutility of care. RESULTS: For first-time symptomatic inguinal hernia repair, first-time small to moderate size ventral hernia repair, and elective laparoscopic cholecystectomy, each workgroup was able to develop one quality, one short-term complication, and one long-term disutility metric. CONCLUSIONS: A structured quality metric design tool facilitates application of knowledge through rapid development of multifaceted, patient-centric outcomes measures by expert minimally invasive surgeons, otherwise not formally trained in metric development. The exercise also highlighted the need to rigorously define denominator populations and to guard against metric-driven undertreatment.

Clinical Predictors of Positive Postoperative Blood Cultures.

OBJECTIVE: To define clinical features of surgical patients in whom postoperative blood cultures are likely to identify pathogens. BACKGROUND: Bacteremia is a worrisome postoperative complication and blood cultures (BCx) are routinely used for evaluation of postoperative bacteremia, but are costly and not always diagnostic. Better methods are needed to select patients in whom BCx identify pathogens. METHODS: We reviewed records of patients ≥18 years old with BCx drawn ≤10 days after surgery in 2013 seeking independent predictors of positive cultures by simple and multiple logistic regression models with statistical significance at α = 0.05. RESULTS: Of 1804 BCx, excluding contaminants yielded 1780 cultures among 746 patients for analysis. The yield was low, with only 4% identifying potential pathogens. Positive BCx were most common after cardiac, ear/nose/throat, obstetric, and urologic procedures [odds ratio (OR) =10.3, P < 0.001 vs low-yield procedures: eg, gynecologic, neurosurgical, plastic surgical, podiatric, transplant]. Cultures more often grew pathogens when drawn in association with higher peak temperature (Tmax, P = 0.001) and longer interval from procedure to Tmax (P = 0.001). Antibiotic therapy at time of culture reduced yield (2.9% with vs 5.5% without antibiotics, P = 0.007). Multivariable logistic regression analysis found antibiotics at culture, procedure specialty, Tmax, and postoperative timing of Tmax were associated with blood culture results. CONCLUSIONS: Ordering blood cultures based on fever or another single predictor inconsistently identifies pathogens. Our dataset, the largest available, identify clinical predictors in the first 10 postoperative days to guide identification of patients with bacteremia.

All in: expansion of the acquisition of data for outcomes and procedure transfer (ADOPT) program to an entire SAGES annual meeting hands-on hernia course.

BACKGROUND: Continuing professional development (CPD) for the surgeon has been challenging because of a lack of standardized approaches of hands-on courses, resulting in poor post-course outcomes. To remedy this situation, SAGES has introduced the ADOPT program, implementing a standardized, long-term mentoring program as part of its hernia hands-on course. Previous work evaluating the pilot program showed increased adoption of learned procedures as well as increased confidence of the mentored surgeons. This manuscript describes the impact of such a program when it is instituted across an entire hands-on course. METHODS: Following collection of pre-course benchmark data, all participants in the 2016 SAGES hands-on hernia course underwent structured, learner-focused instruction during the cadaveric lab. All faculty had completed a standardized teaching course in the Lapco TT format. Subsequently, course participants were enrolled in a year-long program involving longitudinal mentorship, webinars, conference calls, and coaching. Information about participant demographics, training, experience, self-reported case volumes, and confidence levels related to procedures were collected via survey 3 months prior to 9 months after the course. RESULTS: Twenty surgeons participated in the SAGES ADOPT 2016 hands-on hernia program. Of these, seventeen completed pre-course questionnaires (85%), ten completed the 3-month questionnaire (50%), and four completed the 9-month questionnaire (20%). Nine of ten respondents of the 3-month survey (90%) reported changes in their practice. In the 9-month survey, significant increases in the annualized procedural volumes were reported for open primary ventral hernia repair, open components separation, and mesh insertion for ventral hernia repair (p < 0.001). CONCLUSIONS: The expansion of the ADOPT program to an entire hands-on hernia course is both feasible and beneficial, with evidence of Kirkpatrick Levels 1-4a training effectiveness. This expanded success suggests that it is a useful blueprint for the CPD of surgeons wishing to learn new techniques and procedures for their patients.

Hands-on 2.0: improving transfer of training via the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program.

BACKGROUND: Practicing surgeons commonly learn new procedures and techniques by attending a "hands-on" course, though trainings are often ineffective at promoting subsequent procedure adoption in practice. We describe implementation of a new program with the SAGES All Things Hernia Hands-On Course, Acquisition of Data for Outcomes and Procedure Transfer (ADOPT), which employs standardized, proven teaching techniques, and 1-year mentorship. Attendee confidence and procedure adoption are compared between standard and ADOPT programs. METHODS: For the pilot ADOPT course implementation, a hands-on course focusing on abdominal wall hernia repair was chosen. ADOPT participants were recruited among enrollees for the standard Hands-On Hernia Course. Enrollment in ADOPT was capped at 10 participants and limited to a 2:1 student-to-faculty ratio, compared to the standard course 22 participants with a 4:1 student-to-faculty ratio. ADOPT mentors interacted with participants through webinars, phone conferences, and continuous email availability throughout the year. All participants were asked to provide pre- and post-course surveys inquiring about the number of targeted hernia procedures performed and related confidence level. RESULTS: Four of 10 ADOPT participants (40%) and six of 22 standard training participants (27%) returned questionnaires. Over the 3 months following the course, ADOPT participants performed more ventral hernia mesh insertion procedures than standard training participants (median 13 vs. 0.5, p = 0.010) and considerably more total combined procedures (median 26 vs. 7, p = 0.054). Compared to standard training, learners who participated in ADOPT reported greater confidence improvements in employing a components separation via an open approach (p = 0.051), and performing an open transversus abdominis release, though the difference did not achieve statistical significance (p = 0.14). DISCUSSION: These results suggest that the ADOPT program, with standardized and structured teaching, telementoring, and a longitudinal educational approach, is effective and leads to better transfer of learned skills and procedures to clinical practice.

What is the value of the SAGES/AORN MIS checklist? A multi-institutional practical assessment.

BACKGROUND: Surgical safety checklists reduce perioperative complications and mortality. Given that minimally invasive surgery (MIS) is dependent on technology and vulnerable to equipment failure, SAGES and AORN partnered to create a MIS checklist to optimize case flow and minimize errors. The aim of this project was to evaluate the effectiveness of the SAGES/AORN checklist in preventing disruptions and determine its ease of use. METHODS: The checklist was implemented across four institutions and completed by the operating team. To assess its effectiveness, we recorded how often the checklist identified problems and how frequently each of the 45 checklist items were not completed. The perceived usefulness, ease of use, and frustration associated with checklist use were rated on a 5-point Likert scale by the surgeon. We assessed any differences dependent on timing of checklist completion and among institutions. RESULTS: The checklist was performed during MIS procedures (n = 114). When used before the procedure (n = 36), the checklist identified missing items in 13 cases (36.11 %). When used after the procedure (n = 61), the checklist identified missing items in 18 cases (29.51 %) that caused a delay of 4.1 ± 11.1 min. The most frequently missed items included preference card review (14.0 %), readiness of the carbon dioxide insufflator (8.7 %), and availability of the Veress needle (3.6 %). The checklist took an average of 3.6 ± 2.7 min to complete with its usefulness rated 2.6 ± 1.5, ease of use 2.0 ± 1.2, and frustration 1.3 ± 1.1. CONCLUSION: The checklist identified problems in 24 % of cases that led to preventable delays. The checklist was easy to complete and not frustrating, indicating it could improve operative flow. This study also identified the most useful items which may help abbreviate the checklist, minimizing the frustration and time taken to complete it while maximizing its utility. These attributes of the SAGES/AORN MIS checklist should be explored in future larger-scale studies.

SAGE(S) advice: application of a standardized train the trainer model for faculty involved in a Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) hands-on course.

INTRODUCTION: Currently, no prerequisite teaching qualification is required to serve as faculty for SAGES hands-on courses (SAGES-HOC). The Lapco-Train-the-Trainers (Lapco-TT) is a course for surgical trainers, in which delegates learn a standardized teaching technique for skills acquisition. The aims of this study were to 1) determine if this curriculum could be delivered in a day course to SAGES-HOC faculty and 2) assess the impact of such training on learners' educational experience taught by this faculty at a subsequent SAGES-HOC. METHODS AND PROCEDURES: Six experts attended a one-day Lapco-TT course. SAGES-HOC participants were split into two groups: Group A taught by Lapco-TT trained, and Group B by "untrained" course faculty. Opinion surveys were completed by both the SAGES-HOC learners and the Lapco-TT trained course faculty. Furthermore, the latter underwent self-, learner-, and observer-based evaluation using a previously validated teaching assessment tool (cSTTAR). Mean scores were reported and analyzed [Mann-Whitney U, t test (p < 0.05)]. RESULTS: All 6 Lapco-TT delegates found the course useful (5), and felt that it would influence the way they taught in the OR (4.83), that their course objectives were met (4.83), and that they would recommend the course to their colleagues (4.83). Of the SAGES-HOC participants, compared to Group B (n = 22), Group A learners(n = 10) better understood what they were supposed to learn (5 vs. 4.15 [p = 0.046]) and do (5 vs. 4 [p = 0.046]), felt that the session was well organized (5 vs. 4 [p = 0.046]), that time was used effectively (5 vs. 3.9 [p = 0.046]), and that performance feedback was sufficient (5 vs. 3.9 [p = 0.028]) and effective (5 vs. 3.95 [p = 0.028]). Group A faculty were rated significantly higher by their learners on the cSTTARs than Group B (p < 0.0005). Group A faculty rated themselves significantly lower than both expert observers (p < 0.0005) and compared to the Group B faculty's self-assessment (p < 0.002). CONCLUSIONS: The Lapco-TT course can be delivered effectively over one day and impacts the educational experience of learners at a SAGES-HOC. This could help establish a standardized method of teaching at SAGES-HOCs and thereby increase their value for learners.

Carotid endarterectomy under local and/or regional anesthesia has less risk of myocardial infarction compared to general anesthesia: An analysis of national surgical quality improvement program database.

Multiple studies have evaluated the effect of anesthesia type on carotid endarterectomy with inconsistent results. Our study compared 30-day postoperative myocardial infarction, stroke, and mortality between carotid endarterectomy under local or regional anesthesia and carotid endarterectomy under general anesthesia utilizing National Surgical Quality Improvement Program database. All patients listed in National Surgical Quality Improvement Program database that underwent carotid endarterectomy under general anesthesia and local or regional anesthesia from 2005 to 2011 were included with the exception of patients undergoing simultaneous carotid endarterectomy and coronary artery bypass grafting. The data revealed substantial differences between the two groups compared, and these were adjusted using multiple logistic regression. Postoperative myocardial infarction, stroke, and death at 30 days were compared between the two groups. A total of 42,265 carotid endarterectomy cases were included. A total of 37,502 (88.7%) were performed under general anesthesia and 4763 (11.3%) under local or regional anesthesia. Carotid endarterectomy under local or regional anesthesia had a significantly decreased risk of 30-day postoperative myocardial infarction when compared to carotid endarterectomy under general anesthesia (0.4% vs 0.86%, p = 0.012). No statistically significant differences were found in postoperative stroke or mortality. Carotid endarterectomy under local or regional anesthesia carries a decreased risk of postoperative myocardial infarction when compared to carotid endarterectomy under general anesthesia. Therefore, patients at risk of postoperative myocardial infarction undergoing carotid endarterectomy, consideration of local or regional anesthesia may reduce that risk.

Pregnancy Curriculum: Advocating for a Healthier Pregnancy in General Surgery Residency.

INTRODUCTION: With an increasing number of women entering surgical careers, pregnancy amongst surgical residents is anecdotally rising. There is no single resource to inform expectant surgical residents of potential occupational risks, or to help them optimize workplace safety during and after pregnancy. The aim of this initiative is to provide surgical residents with an overview of residency occupational risks applicable to maternal-fetal health, propose systemic and situational modifications, and to empower pregnant residents to better plan and advocate for a healthy pregnancy. METHODS: Surgery department staff were invited to contribute to the pregnancy curriculum at the authors' institution. Feedback was received from attending physicians and surgical residents (N = 12), as well as all female residents having experienced in-training pregnancy or early child-rearing from 2017 to 2022 (N = 6). After identifying workplace hazard and compiling staff feedback, the authors developed a set of recommendations for the protection of pregnant and early-parenting female trainees. RESULTS: Five areas of process improvements were identified for the protection of pregnant residents: culture, ergonomics, exposure, maternal & fetal care, and fourth trimester support. Specific recommendations ranged from widespread institutional support emphasizing psychological safety and zero-retaliation policies, to healthcare-related hazard exposure protections, as well as tangible postpartum and lactation support. Out of this initiative came the pregnancy curriculum. CONCLUSION: Widespread and decisive institutional support is paramount to cultural shifts surrounding in-training pregnancy. The guidelines proposed in this project are intended to be enforced by surgical residency leadership with the precise goal of removing the cultural burden from the expectant resident. Only the resident herself can thereafter chose to adopt or decline the protective measures. Through our recommendations, we hope to offer a foundation upon which individual residents and program leaders can build tailored, pregnancy-specific interventions, with the ultimate goal of improving the antenatal outcomes of our trainees and their growing families without compromising surgical training.