Behind the pattern: General surgery residsent autonomy in robotic surgery.

Objective: Robotic surgery is increasingly utilized and common in general surgery training programs. This study sought to better understand the factors that influence resident operative autonomy in robotic surgery. We hypothesized that resident seniority, surgeon work experience, surgeon robotic-assisted surgery (RAS) case volume, and procedure type influence general surgery residents' opportunities for autonomy in RAS as measured by percentage of resident individual console time (ICT). Methods: General surgery resident ICT data for robotic cholecystectomy (RC), inguinal hernia (RIH), and ventral hernia (RVH) operations performed on the dual-console Da Vinci surgical robotic system between July 2019 and June 2021 were extracted. Cases with postgraduate year (PGY) 2-5 residents participating as a console surgeon were included. A sequential explanatory mixed-methods approach was undertaken to explore the ICT results and we conducted secondary qualitative interviews with surgeons. Descriptive statistics and thematic analysis were applied. Results: Resident ICT data from 420 robotic cases (IH 200, RC 121, and VH 99) performed by 20 junior residents (PGY2-3), 18 senior residents (PGY4-5), and 9 attending surgeons were extracted. The average ICT per case was 26.8 % for junior residents and 42.4 % for senior residents. Compared to early-career surgeons, surgeons with over 10 years' work experience gave less ICT to junior (18.2 % vs. 32.0 %) and senior residents (33.9 % vs. 56.6 %) respectively. Surgeons' RAS case volume had no correlation with resident ICT (r = 0.003, p = 0.0003). On average, residents had the most ICT in RC (45.8 %), followed by RIH (36.7 %) and RVH (28.6 %). Interviews with surgeons revealed two potential reasons for these resident ICT patterns: 1) Surgeon assessment of resident training year/experience influenced decisions to grant ICT; 2) Surgeons' perceived operative time pressure inversely affected resident ICT. Conclusions: This study suggests resident ICT/autonomy in RC, RIH, and RVH are influenced by resident seniority level, surgeon work experience, and procedure type, but not related to surgeon RAS case volume. Design and implementation of an effective robotic training program must consider the external pressures at conflict with increased resident operative autonomy and seek to mitigate them.

Laparoscopic vs robotic inguinal hernia repair: a comparison of learning curves and skill transference in general surgery residents.

BACKGROUND: There is no consensus on whether laparoscopic experience should be a prerequisite for robotic training. Further, there is limited information on skill transference between laparoscopic and robotic techniques. This study focused on the general surgery residents' learning curve and skill transference within the two minimally invasive platforms. METHODS: General surgery residents were observed during the performance of laparoscopic and robotic inguinal hernia repairs. The recorded data included objective measures (operative time, resident participation indicated by percent active time on console or laparoscopy relative to total case time, number of handoffs between the resident and attending), and subjective evaluations (preceptor and trainee assessments of operative performance) while controlling for case complexity, patient comorbidities, and residents' prior operative experience. Wilcoxon two-sample tests and Pearson Correlation coefficients were used for analysis. RESULTS: Twenty laparoscopic and forty-four robotic cases were observed. Mean operative times were 90 min for robotic and 95 min for laparoscopic cases (P = 0.4590). Residents' active participation time was 66% on the robotic platform and 37% for laparoscopic (P = < 0.0001). On average, hand-offs occurred 9.7 times during robotic cases and 6.3 times during laparoscopic cases (P = 0.0131). The mean number of cases per resident was 5.86 robotic and 1.67 laparoscopic (P = 0.0312). For robotic cases, there was a strong correlation between percent active resident participation and their prior robotic experience (r = 0.78) while there was a weaker correlation with prior laparoscopic experience (r = 0.47). On the other hand, prior robotic experience had minimal correlation with the percent active resident participation in laparoscopic cases (r = 0.12) and a weak correlation with prior laparoscopic experience (r = 0.37). CONCLUSION: The robotic platform may be a more effective teaching tool with a higher degree of entrustability indicated by the higher mean resident participation. We observed a greater degree of skill transference from laparoscopy to the robot, indicated by a higher degree of correlation between the resident's prior laparoscopic experience and the percent console time in robotic cases. There was minimal correlation between residents' prior robotic experience and their participation in laparoscopic cases. Our findings suggest that the learning curve for the robot may be shorter as prior robotic experience had a much stronger association with future robotic performance compared to the association observed in laparoscopy.

Structured Resident Training in Robotic Surgery: Recommendations of the Robotic Surgery Education Working Group.

OBJECTIVE: A universal resident robotic surgery training pathway that maximizes proficiency and safety has not been defined by a consensus of surgical educators or by surgical societies. The objective of the Robotic Surgery Education Working Group was to develop a universal curriculum pathway and leverage digital tools to support resident education. DESIGN: The two lead authors (JP and YN) contacted potential members of the Working Group. Members were selected based on their authorship of peer-review publications, their experience as minimally invasive and robotic surgeons, their reputations, and their ability to commit the time involved to work collaboratively and efficiently to reach consensus regarding best practices in robotic surgery education. The Group's approach was to reach 100% consensus to provide a transferable curriculum that could be applied to the vast majority of resident programs. SETTING: Virtual and in-person meetings in the United States. PARTICIPANTS: Eight surgeons (2 females and 6 males) from five academic medical institutions (700-1541 beds) and three community teaching hospitals (231-607 beds) in geographically diverse locations comprised the Working Group. They represented highly specialized general surgeons and educators in their mid-to-late careers. All members were experienced minimally invasive surgeons and had national reputations as robotic surgery educators. RESULTS: The surgeons initially developed and agreed upon questions for each member to consider and respond to individually via email. Responses were collated and consolidated to present on an anonymized basis to the Group during an in-person day-long meeting. The surgeons self-facilitated and honed the agreed upon responses of the Group into a 5-level Robotic Surgery Curriculum Pathway, which each member agreed was relevant and expressed their convictions and experience. CONCLUSIONS: The current needs for a universal robotic surgery training curriculum are validated objective and subjective measures of proficiency, access to simulation, and a digital platform that follows a resident from their first day of residency through training and their entire career. Refinement of current digital solutions and continued innovation guided by surgical educators is essential to build and maintain a scalable, multi-institutional supported curriculum.

Common Components of General Surgery Robotic Educational Programs.

OBJECTIVE: Robotically assisted surgery has become more common in general surgery, but there is limited guidance from the Accreditation Council for Graduate Medical Education (ACGME) regarding this type of training. We sought to determine common elements and differences in the robotic educational curricula developed by general surgery residency programs. DESIGN: Robotic educational curricula were obtained from the 7 individuals who presented at the workshop, "Robotic Education in General Surgery" at the 2023 Association of Program Directors in Surgery annual meeting. RESULTS: All 7 general surgery programs had training beginning intern year, required online robotic modules, had at least 1 dedicated simulation training console not used for clinical purposes, and ran dry and wet (tissue) robotic labs at least annually. All programs had bedside and console surgeon case minimums and had administrative support to run the educational programs. Differences existed regarding how training intern year was executed, the simulations required, clinical practice minimum requirements, how progress was monitored over time, and how case numbers were tracked. Some programs had salary support for a director of robotic education. CONCLUSIONS: There are several common elements to robotic educational curricula in general surgery, however significant variation does exist between programs. Given the frequency of robotic use in general surgery and current lack of standardization, formal guidance from the ACGME specifically regarding robotic education in general surgery residency is warranted.

What influences general surgery residents' prospective entrustment and operative time in robotic inguinal hernia repairs.

INTRODUCTION: Teaching residents robotic-assisted inguinal hernia repair (RIHR) is an increasingly common extension of contemporary surgical training. This study sought to investigate what variables would influence operative time (OT) and resident prospective entrustment in RIHR cases. METHODS: We prospectively collected 68 resident RIHR operative performance evaluations with a validated instrument. Outpatient RIHR cases performed by 11 general surgery residents during 2020-2022 were included. The overall OT of matched cases was extracted from hospital billing; matched procedural step-specific OT was obtained from Intuitive Data Recorder (IDR). Statistical analysis was performed using Pearson correlation and one-way ANOVA. RESULTS: The evaluation instrument reliably assessed residents' RIHR performance (Cronbach's α = 0.93); residents' prospective entrustment strongly correlated with overall guidance provided by attending surgeon (r = 0.86, p < 0.0001) and operative plan and judgment (r = 0.85, p < 0.0001). The overall OT was significantly associated with resident's team management (r = - 0.35, p = 0.011). Procedural step-specific OT was significantly associated with residents' step-specific skill (r = - 0.32, p = 0.014). On average, RIHR cases with the highest level of prospective entrustment (Resident can teach junior) showed the shortest step-specific OT. Entrustment level 3 (Reactive guidance needed) was the turning point of all four RIHR procedural step-specific OT. CONCLUSIONS: Our findings suggest that in RIHR, attending guidance, resident operative plan and judgment, and resident technical skill contribute to resident prospective entrustment; resident team management, technical skill, and attending guidance influence operative time, which in turn impacts attendings' determination of resident prospective entrustment. Future studies with a larger sample size are needed to further validate the findings.

Is Robotic Console Time a Surrogate for Resident Operative Autonomy?

OBJECTIVE: Robotic-assisted surgery is an increasing part of general surgery training, but resident autonomy on the robotic platform can be hard to quantify. Robotic console time (RCT), the percentage of time the resident controls the console, may be an appropriate measure of resident operative autonomy. This study aims to characterize the correlation between objective resident RCT and subjectively scored operative autonomy. METHODS: Using a validated resident performance evaluation instrument, we collected resident operative autonomy ratings from residents and attendings performing robotic cholecystectomy (RC) and robotic inguinal hernia repair (IH) at a university-based general surgery program between 9/2020-6/2021. We then extracted RCT data from the Intuitive surgical system. Descriptive statistics, t-tests and ANOVA were performed. RESULTS: A total of 31 robotic operations (13 RC, 18 IH) performed by 4 attending surgeons and 8 residents (4 junior, 4 senior) were matched and included. 83.9% of cases were scored by both attending and resident. The average RCT per case was 35.6%(95% CI 13.0%,58.3%) for junior residents (PGY 2-3) and 59.7%(CI 51.1%,68.3%) for senior residents (PGY 4-5). The mean autonomy evaluated by residents was 3.29(CI 2.85,3.73) out of a maximum score of 5, while the mean autonomy evaluated by attendings was 4.12(CI 3.68,4.55). RCT significantly correlated with subjective evaluations of resident autonomy (r=0.61, p=0.0003). RCT also moderately correlated with resident training level (r=0.5306, p<0.0001). Neither attending robotic experience nor operation type significantly correlated with RCT or autonomy evaluation scores. CONCLUSIONS: Our study suggests that resident console time is a valid surrogate for resident operative autonomy in robotic cholecystectomy and inguinal hernia repair. RCT may be a valuable measure in objective assessment of residents' operative autonomy and training efficiency. Future investigation into how RCT correlates with subjective and objective autonomy metrics such as verbal guidance or distinguishing critical operative steps is needed to validate the study findings further.

Robotic Enhanced-View Totally Extraperitoneal vs Intraperitoneal Onlay Mesh Evaluation: 1-Year Exploratory Outcomes of the REVEAL Randomized Clinical Trial.

BACKGROUND: Patients with small- to medium-sized ventral hernias randomized to robotic enhanced-view totally extraperitoneal (eTEP) or robotic intraperitoneal onlay mesh (rIPOM) previously demonstrated comparable 30-day patient-reported outcomes. Here we report 1-year exploratory outcomes for this multi-center, patient-blinded randomized clinical trial. STUDY DESIGN: Patients with midline ventral hernias 7 cm wide or less undergoing mesh repair were randomized to robotic eTEP or rIPOM. Planned exploratory outcomes at 1 year include pain intensity (using the Patient-Reported Outcomes Measurement Information System [PROMIS 3a]), Hernia-Related Quality of Life Survey (HerQLes) scores, pragmatic hernia recurrence, and reoperation. RESULTS: One hundred randomized patients (51 eTEP, 49 rIPOM) reached a median 12-month follow-up (interquartile range 11 to 13) with 7% lost. After regression analysis adjusting for baseline scores, there was no difference in postoperative pain intensity at 1-year for eTEP compared with rIPOM (odds ratio [OR] 2.1 [95% CI 0.85 to 5.1]; p = 0.11). HerQLes scores were 15 points lower on average (ie less improved) at 1 year after eTEP repairs compared with rIPOM, a difference maintained after regression analysis (OR 0.31 [95% CI 0.15 to 0.67]; p = 0.003). Pragmatic hernia recurrence was 12.2% (6 of 49) for eTEP and 15.9% (7 of 44) for rIPOM (p = 0.834). In the first year, 2 eTEP and 1 rIPOM patients required reoperations related to their index repair (p = 0.82). CONCLUSIONS: Exploratory analyses showed similar outcomes at 1 year in regard to pain, hernia recurrence, and reoperation. Abdominal wall quality of life at 1 year appears to favor rIPOM, and the possibility that an eTEP dissection is less advantageous in that regard should be the subject of future investigation.

What factors impact surgical operative time when teaching a resident in the operating room.

Purpose: Resident involvement would likely lead to prolonged operative time of a surgical case performed at academic medical centers. However, little is known about factors beneath this phenomenon. The purpose of this study was to investigate whether factors from case (procedure type, surgical case complexity, and surgical approach), teacher (attending surgeon experience and gender), and learner (resident postgraduate training year and gender) would influence operative time of surgical cases involved teaching a resident (SCT). Methods: A single-institution retrospective analysis of 3 common general surgery procedures, including cholecystectomies, colectomies, and inguinal hernia, with involvement of general surgery residents between 2016 and 2020 was conducted. Surgical operative time was defined as the "cut-to-close" time from incision to completion of wound closure. Analysis of variance for continuous variables and multivariable linear regression were applied. Results: A total of 4,417 eligible SCT were included. The average operative time was 114.8 ± 78.7 min. SCT with male resident involvement showed a significantly longer operative time than those with female residents (117 vs. 112, p = 0.01). Comparable operative time was observed between male and female attending surgeon cases (115.5 vs. 110.8, p = 0.15). SCT operating time decreased with increased resident training level, except for SCT with involvement of Year2 residents. SCT with Year5 residents demonstrated the lowest time to case completion (110.5 min); SCT with major complications took least time to complete (105.7 min). Univariate and multivariate analysis revealed resident training year level, resident gender, and case complexity as factors associated with significant differences in operative time. Attending surgeon experience, surgeon gender, surgical approach, and procedure type did not impact SCT operative time. Conclusion: Our study findings suggest resident training level, resident gender, and case complexity are factors significantly associated with SCT operative time of cholecystectomies, colectomies, and inguinal hernia. Attending surgeons are recommended to factor them into pre-operative planning.

Distortions in the Balance Between Teaching and Efficiency in the Operating Room.

INTRODUCTION: The balance between teaching and operative efficiency (i.e., continuing operative case progression) is difficult for even the most experienced master surgeon educators. The purpose of this study was to explore influencing factors behind attending surgeons' decisions to break the balance between operative efficiency and teaching in the operating room. METHODS: Semistructured interviews were conducted with surgeons across the United States via Web-based video conferencing. The interviews were audio-recorded and transcribed. Qualitative analysis using the framework method was utilized, and emergent themes were identified. RESULTS: Twenty-three attending surgeons from 8 academic institutions and 11 surgical specialties completed interviews (14 men and 9 women). Attending surgeons consider a variety of factors associated with their dual roles (surgeon versus teacher) when balancing operative efficiency and providing appropriate independence for residents with oversight to promote autonomy. These were divided into surgeon-role-related factors (patient safety, financial factors, scheduling factors, preservation of faculty reputation for efficiency, and mode of operation) as well as teacher-role-related factors (preparation, level, and technical skill of the resident). These factors then informed attending surgeons' determinations about how the case was progressing, which prompted them to intervene and reduce resident autonomy or allow the resident to continue. CONCLUSIONS: Surgeons consider numerous factors when deciding how to balance resident teaching and autonomy while preserving operative efficiency. These findings provide helpful insights for surgical departments to consider inclusion in faculty-development programs, resident education, and systematic improvements.

Cost analysis of training residents in robotic-assisted surgery.

INTRODUCTION: Use of robotic-assisted surgery is increasing, and resident involvement may lead to higher costs. We investigated whether senior resident involvement in noncomplex robotic cholecystectomy (RC) and inguinal hernia (RIH) would take more time and cost more when compared to non-robotic cholecystectomy (NRC) and inguinal hernia repair (NRIH). METHODS: We extracted surgery duration and total cost of NRC, NRIH, RC, and RIH from 7/2016 to 6/2020 with senior resident (PGY4-5) involvement. We excluded complex cases as well as prisoner cases and those with new faculty and research residents. We assessed differences between robotic and non-robotic cases in surgery duration and total cost per minute, using one-way ANOVA. RESULTS: We included 1608 cases (non-robotic 1145 vs. robotic 463). On average, RC cases with a senior resident took less time than NRC (179.4 < 185.8, p = 0.401); surgery duration of RIH cases was similar with NRIH cases. The total cost per minute of RC cases with a senior resident on average was $9.30 higher than NRC cases for each minute incurred in the operating room but did not lead to a significant change in overall cost. RIH cases, on the other hand, cost less per minute than NRIH cases (114.1 < 126.5, p = 0.399). CONCLUSION: Training in robotic surgery is important. Noncomplex RC and RIH involving senior residents were not significantly longer nor did they incur significantly more cost than non-robotic procedures. Senior resident training in noncomplex robotic surgery can be efficient and can be included in the residency curriculum.

The robot doesn't lie: real-life validation of robotic performance metrics.

BACKGROUND: Degree of resident participation in a case is often used as a surrogate marker for operative autonomy, an essential element of surgical resident training. Previous studies have demonstrated a considerable disagreement between the perceptions of attending surgeons and trainees when it comes to estimating operative participation. The Da Vinci Surgical System dual console interface allows machine generated measurements of trainee's active participation, which has the potential to obviate the need for labor intensive direct observation of surgical procedures. However, the robotic metrics require validation. We present a comparison of operative participation as perceived by the resident, faculty, trained research staff observer (gold standard), and robotic machine generated data. METHODS: A total of 28 consecutive robotic inguinal hernia repair procedures were observed by research staff. Operative time, percent active time for the resident, and number of handoffs between the resident and attending were recorded by trained research staff in the operating room and the Da Vinci Surgical System. Attending and resident evaluations of operative performance and perceptions of percent active time for the resident were collected using standardized forms and compared with the research staff observed values and the robot-generated console data. Wilcoxon two-sample tests and Pearson Correlation coefficients statistical analysis were performed. RESULTS: Robotic inguinal hernia repair cases had a mean operative time of 91.3 (30) minutes and an attending-rated mean difficulty of 3.1 (1.26) out of 5. Residents were recorded to be the active surgeon 71.8% (17.7) of the total case time by research staff. There was a strong correlation (r = 0.77) in number of handoffs between faculty and trainee as recorded by the research staff and robot (4.28 (2.01) vs. 5.8 (3.04) respectively). The robotic machine generated data demonstrated the highest degree of association when compared to the gold standard (research staff observed data), with r = 0.98, p < 0.0001. Lower levels of association were seen with resident reported (r = 0.66) perceptions and faculty-reported (r = 0.55) perceptions of resident active operative time. CONCLUSIONS: Our findings suggest that robot-generated performance metrics are an extremely accurate and reliable measure of intraoperative resident participation indicated by a very strong correlation with the data recorded by research staff's direct observation of the case. Residents demonstrated a more accurate awareness of their degree of participation compared with faculty surgeons. With high accuracy and ease of use, robotic surgical system performance metrics have the potential to be a valuable tool in surgical training and skill assessment.

Robotic eTEP versus IPOM evaluation: the REVEAL multicenter randomized clinical trial.

BACKGROUND: For small to medium-sized ventral hernias, robotic intraperitoneal onlay mesh (rIPOM) and enhanced-view totally extraperitoneal (eTEP) repair have emerged as acceptable approaches that each takes advantage of robotic instrumentation. We hypothesized that avoiding mesh fixation in a robotic eTEP repair offers an advantage in early postoperative pain compared to rIPOM. METHODS: This is a multi-center, randomized clinical trial for patients with midline ventral hernias ≤ 7 cm, who were randomized to rIPOM or robotic eTEP. The primary outcome was pain (0-10) on the first postoperative day. Secondary outcomes included same-day discharge, length of stay, opioid consumption, quality of life, surgeon workload, and cost. RESULTS: Between November 2019 and November 2021, 100 patients were randomized (49 rIPOM, 51 eTEP) among 5 surgeons. Pain on the first postoperative day [median (IQR): 5 (4-6) vs. 5 (3.5-7), p = 0.66] was similar for rIPOM and eTEP, respectively, a difference maintained following adjustments for surgeon, operative time, baseline pain, and patient co-morbidities (difference 0.28, 95% CI - 0.63 to 1.19, p = 0.56). No differences in pain on the day of surgery, 7, and 30 days after surgery were identified. Same-day discharge, length of stay, opioid consumption, and 30-day quality of life were also comparable, though rIPOM required less surgeon workload (p < 0.001), shorter operative time [107 (86-139) vs. 165 (129-212) min, p < 0.001], and resulted in fewer surgical site occurrences (0 vs. 8, p = 0.004). The total direct costs for rIPOM and eTEP were comparable [$8282 (6979-11835) vs. $8680 (7550-10282), p = 0.52] as the cost savings for eTEP attributable to mesh use [$442 (434-485) vs. $69 (62-76), p = < 0.0001] were offset by increased expenses for operative time [$669 (579-861) vs. $1075 (787-1367), p < 0.0001] and use of more robotic equipment [$760 (615-933) vs. $946 (798-1203), p = 0.001]. CONCLUSION: The avoidance of fixation in a robotic eTEP repair did not reveal a benefit in postoperative pain to offset the shorter operative time and surgeon workload offered by rIPOM.

Association of Impaired Fasting Blood Glucose With Triple Coronary Artery Stenosis and Myocardial Infarction Among Patients With Coronary Artery Stenosis.

Background: The association between impaired fasting glucose level (IFG) and coronary heart disease (CAD) remain controversial. In the present study, we sought to ascertain a relationship of IFG with the number of diseased coronary artery and occurrence of myocardial infarction, among CAD cases. Methods: We studied 1,451 consecutive no-diabetic patients who underwent coronary angiography at the First Affiliated Hospital of Shantou University Medical College in Southern China. Demographic, biochemical, clinical and angiographic data were collected. Results: The prevalence of IFG was higher in patients with angiographically confirmed CAD than in subjects without angiographic evidence of CAD (33.4 versus 28.2%, p = 0.034). Compared with CAD cases without IFG, CAD cases with IFG had a higher odds ratio (OR) of having triple-vessel disease as opposed to having single- or double-vessel disease [OR = 1.53, 95% confidence interval (CI) = 1.13-2.07]. Furthermore, the occurrence of MI was higher in CAD cases with IFG than in CAD cases without IFG (OR = 1.73, 95% CI = 1.27-2.36). Conclusions: There is an association between IFG and a predisposition to severe CAD indicated by triple vessel disease or myocardial infarction.

Outcomes of inpatient cholecystectomy among adults with cystic fibrosis in the United States.

BACKGROUND: Symptomatic biliary and gallbladder disorders are common in adults with cystic fibrosis (CF) and the prevalence may rise with increasing CF transmembrane conductance regulator modulator use. Cholecystectomy may be considered, but the outcomes of cholecystectomy are not well described among modern patients with CF. AIM: To determine the risk profile of inpatient cholecystectomy in patients with CF. METHODS: The Nationwide Inpatient Sample was queried from 2002 until 2014 to investigate outcomes of cholecystectomy among hospitalized adults with CF compared to controls without CF. A propensity weighted sample was selected that closely matched patient demographics, patient's individual comorbidities, and hospital characteristics. The propensity weighted sample was used to compare outcomes among patients who underwent laparoscopic cholecystectomy. Hospital outcomes of open and laparoscopic cholecystectomy were compared among adults with CF. RESULTS: A total of 1239 inpatient cholecystectomies were performed in patients with CF, of which 78.6% were performed laparoscopically. Mortality was < 0.81%, similar to those without CF (P = 0.719). In the propensity weighted analysis of laparoscopic cholecystectomy, there was no difference in mortality, or pulmonary or surgical complications between patients with CF and controls. After adjusting for significant covariates among patients with CF, open cholecystectomy was independently associated with a 4.8 d longer length of stay (P = 0.018) and an $18449 increase in hospital costs (P = 0.005) compared to laparoscopic cholecystectomy. CONCLUSION: Patients with CF have a very low mortality after cholecystectomy that is similar to the general population. Among patients with CF, laparoscopic approach reduces resource utilization and minimizes post-operative complications.

Expectations versus reality: trainee participation on the robotic console in academic surgery.

INTRODUCTION: Trainees underestimate the amount of operative autonomy they receive, whereas faculty overestimate; this has not been studied in robotics. We aimed to assess the perceptions and expectations of our general surgery trainees and faculty on robotic console participation in academic surgery. METHODS: A survey was administered to general surgery robotic faculty and trainees eligible to sit at the console. Participants estimated the average percentage of trainee console participation time (CPT) per case for robotic cholecystectomies (CCY) and inguinal hernia repairs (IHR) from January to June 2019. Trainees were additionally asked what CPT they expected according to their training level (novice or senior). Expected CPTs were compared to actual CPTs extracted from robotic console logs during the same time frame. RESULTS: Survey response rate was 80% for faculty (4 of 5) and 65% for trainees (15 of 23). Novices expected a higher CPT than they perceived in CCY (42.8% ± 14.8% vs 19.0% ± 17.2%, p = 0.03) and IHR (36.1% ± 17.6% vs. 10.7% ± 13.7%, p = 0.01), but in actuality, they did more CPT than perceived (by 34.9% in CCY, p < 0.01; 14% in IHR, p = 0.10). Senior trainees accurately perceived their CPT in IHR, but expected a higher CPT by 15.9% (p = 0.04). In CCY, seniors perceived a 23.8% higher CPT than in reality (p = 0.04). Faculty generally overperceived trainee CPT by 12.8-16.3% (p > 0.05). Compared to faculty, novices perceived lower CPTs in both CCY by 29.9% (p = 0.16) and IHR by 26.8% (p = 0.07), but seniors tended to agree with the faculty-perceived CPTs (p > 0.05). CONCLUSION: Our robotic trainees expect to do more on the console than they perceive. Faculty think they allow their trainees more participation than in reality. Compared to faculty perception, novice trainees perceive a much lower level of trainee participation than senior trainees do. Expectation setting and standardizing learning curves are important for robotic surgery training.

Uterine fibroids increase the risk of hypertensive disorders of pregnancy: a prospective cohort study.

OBJECTIVE: It is unclear whether uterine fibroids are associated with the occurrence of hypertensive disorders of pregnancy (HDP). Thus, this study aimed to evaluate the association between uterine fibroids and HDP in a prospective cohort. METHODS: Overall, 2404 pregnant women who received antenatal care were enrolled in a prospective cohort in China between 2014 and 2016; 2277 women met the inclusion criteria of this study. The clinical characteristics of participants were assessed via questionnaires and physical examinations at baseline (before the 20th week of gestation), 21st-27th, 28th-34th, and 35th-39th gestational weeks. Ultrasound examination was performed before the 20th week of pregnancy to determine the presence of uterine fibroids. Linear mixed-effect and Cox proportional hazard regression models were used to analyze the association of uterine fibroids with blood pressure and HDP. RESULTS: Of 2277 pregnant women, 242 (10.6%) had uterine fibroids, and 45 (2.0%) subsequently developed HDP. The incidence of HDP in women with and without uterine fibroids was 5% (n = 12) and 1.6% (n = 33), respectively. The longitudinal SBPs and DBPs were significantly higher in women with uterine fibroids than in those without. The multivariable Cox model showed that the presence of uterine fibroids was associated with increased HDP risk (adjusted hazard radio: 2.95, 95% confidence interval: 1.35-6.44). CONCLUSION: Uterine fibroids in early pregnancy were associated with an increased HDP risk. Blood pressure of women with uterine fibroids should be closely monitored, and HDP preventive measures are crucial.

The application of meteorological data and search index data in improving the prediction of HFMD: A study of two cities in Guangdong Province, China.

Hand, foot and mouth disease (HFMD) is a public health issue in China, and its incidence in Guangdong Province is higher than the national average. Previous studies have found climatic factors have an influential role in the transmission of HFMD. Internet search technology has been shown to predict some infectious disease epidemics and is a potential resource in tracking epidemics in countries where the use of Internet search index data is prevalent. This study aims to improve the prediction of HFMD in two Chinese cities, Shantou and Shenzhen in Guangdong Province, applying both meteorological data and Baidu search indices to create a HFMD forecasting model. To this end, the relationship between meteorological factors and HFMD was found to be linear in both cities, while the relationship between search engine data and HFMD was not consistent. The results of our study suggest that using both Internet search and meteorological data can improve the prediction of HFMD incidence. Using comparative analysis of both cities, we posit that improved quality search indices enhance prediction of HFMD.

Emergency Presentations of Diverticulitis.

Acute diverticulitis is a common condition that has been increasing in incidence in the United States. It is associated with increasing age, but the pathophysiology of acute diverticulitis is still being elucidated. It is now believed to have a significant contribution from inflammatory processes rather than being a strictly infectious process. There are still many questions to be answered regarding the optimal management of acute diverticulitis because recent studies have challenged traditional practices, such as the routine use of antibiotics, surgical technique, and dietary restrictions for prevention of recurrence.

Identifying Priorities for Faculty Development in General Surgery Using the Delphi Consensus Method.

OBJECTIVE: Faculty teaching skills are critical for effective surgical education, however, which skills are most important to be taught in a faculty development program have not been well defined. The objective of this study was to identify priorities for faculty development as perceived by surgical educators. DESIGN: We used a modified Delphi methodology to assess faculty perceptions of the value of faculty development activities, best learning modalities, as well as barriers and priorities for faculty development. An expert panel developed the initial survey and distributed it to the membership of the Association of Program Directors in Surgery. Responses were reviewed by the expert panel and condensed to 3 key questions that were redistributed to the survey participants for final ranking. PARTICIPANTS: Seven experts reviewed responses to 8 questions by 110 participants. 35 participants determined the final ranking responses to 3 key questions. RESULTS: The top three priorities for faculty development were: 1) Resident assessment/evaluation and feedback 2) Coaching for faculty teaching, and 3) Improving intraoperative teaching skills. The top 3 learning modalities were: 1) Coaching 2) Interactive small group sessions, and 3) Video-based education. Barriers to implementing faculty development included time limitations, clinical workload, faculty interest, and financial support. CONCLUSIONS: Faculty development programs should focus on resident assessment methods, intraoperative and general faculty teaching skills using a combination of coaching, small group didactic and video-based education. Concerted efforts to recognize and financially reward the value of teaching and faculty development is required to support these endeavors and improve the learning environment for both residents and faculty.