Transition to Value-based Healthcare: Development, Implementation, and Results of an Optimal Surgical Care Framework at a National Cancer Institute-designated Comprehensive Cancer Center.

BACKGROUND: The continued rise in healthcare expenditures has not produced commensurate improvements in patient outcomes, leading US healthcare stakeholders to emphasize value-based care. Transition to such a model requires all team members to adopt a new strategic and organizational framework. OBJECTIVE: To describe and report a strategy for the implementation of a novel patient-centered value-based "optimal surgical care" (OSC) framework, with validation and cost analysis in kidney surgery. DESIGN, SETTING, AND PARTICIPANTS: An observational study of care episodes at a single institution from 2014 to 2019 was conducted. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multidisciplinary teams defined OSC by core and procedure-specific metrics using a combination of provider-based ("bottom-up") and "clinical leadership"-based ("top-down") strategies. Baseline OSC rates across were established, while identifying proportions of OSC achieved by coefficient of variation (CV) in total direct costs. Multivariable linear regression comparing cost between OSC and non-OSC encounters was performed, adjusting for patient characteristics. RESULTS AND LIMITATIONS: An analysis of 30 261 perioperative care episodes was performed. Following the implementation of an OSC framework, there was an increase in OSC rates across all procedure buckets using core (25%) and procedure-specific (26%) metrics. Among the tumors tested, kidney cancer surgical episodes held the highest OSC rate improvement (67%) with lowest variability in cost (CV 0.5). OSC was associated with significant total cost savings across all tumor types after adjusting for inflation (p < 0.05). Compared with non-OSC episodes, a significant reduction in the cost ratio of OSC was noted for renal surgery (p < 0.01), with estimated costs savings of $2445.87 per OSC encounter. CONCLUSIONS: Institutional change directing efforts toward optimizing surgical care and emphasizing value rather than focusing solely on expense reduction is associated with improved outcomes, while potentially reducing costs. The strategy for implementation requires serial performance analyses, engaging and educating providers, and continuous ongoing adjustments to achieve durable results. PATIENT SUMMARY: In this study, we report our strategy and outcomes for transitioning to a value-based healthcare model using a novel "optimal surgical care" framework at a National Cancer Institute-designated comprehensive cancer center. We observed an increase in optimal surgical care episodes across all specialties after 5 yr, with a potential associated reduction in cost expenditure. We conclude that the key to a successful and sustained transition is the implementation strategy, focusing on continual review and provider engagement.

Incisional hernia after cystectomy: incidence, risk factors and anthropometric predisposition.

INTRODUCTION: Postoperative incisional hernias (PIH) are an established complication of abdominal surgery with rates after radical cystectomy (RC) poorly defined. The objective of this analysis is to compare rates and risk factors of PIH after open (ORC) and robotic-assisted (RARC) cystectomy at a tertiary-care referral center. MATERIALS AND METHODS: We performed a retrospective review of patients undergoing ORC and RARC from 2000-2015 with pre and postoperative cross-sectional imaging available. Images were evaluated for anthropometric measurements and presence of postoperative radiographic PIH (RPIH). Patient demographics, type of urinary diversion and postoperative hernia repair (PHR) were also assessed. RESULTS: Of the patients that met inclusion criteria (n = 469), the incidence of RPIH and PHR were 14.3% and 9.0%, respectively. Between ORC and RARC, analysis revealed no statistically significant differences in rates of RPIH (13.6% versus 20.3%, p = 0.152) or PHR (8.2% versus 12.5%, p = 0.214). Body mass index was associated with a slightly increased likelihood of RPIH on univariate analysis alone (OR 1.08, p = 0.008). Ileal conduit was associated with a decreased likelihood of RPIH (OR 0.42, p = 0.034) and PHR (OR 0.36, p = 0.023). Supraumbilical rectus diastasis width (RDW) was an independent predictor of both RPIH (OR 1.52, p = 0.023) and PHR (OR 1.43, p = 0.039) on multivariate analysis. CONCLUSIONS: Patients undergoing RC are at significant risk of RPIH and PHR regardless of surgical approach. Anthropomorphic factors and urinary diversion type appear to be associated with PIH risk. Further research is needed to understand how risks of PIH can be reduced in patients undergoing cystectomy.

Initial application of reduced port surgery using the single port access technique for laparoscopic canine ovariectomy.

OBJECTIVE: To describe the Single port access (SPA) laparoscopic entry technique for canine ovariectomy (OVE), report complications, and outcomes. STUDY DESIGN: Pilot study. ANIMALS: Intact female dogs (n = 6). METHODS: With owner consent, 6 intact female dogs had SPA laparoscopic OVE. Data, including signalment, surgical time (from incision to completion of closure), size and location of port placement, need for conversion (both to standard multiport laparoscopy and laparotomy), as well as any intraoperative complications including blood loss or tissue injury were recorded. RESULTS: Mean surgical time was 52.5 minutes (range, 45-60 minutes) and mean incision length, 1.8 cm (range, 1.5-2.0 cm). In an 18-kg mix breed dog (dog 3), a "single port rescue" was required and located on midline 2-cm caudal to the umbilicus. Close positioning of the trocars caused instrument interference, limited viewing, and prevented safe ligation of the ovarian vessels vein with a vessel-sealing device. OVE was successfully completed laparoscopically in all dogs. CONCLUSION: The SPA laparoscopic entry technique can be used in dogs, although instrument and camera interference can occur if trocar placement is too consolidated within the initial skin incision.

The road to reduced port surgery: from single big incisions to single small incisions, and beyond.

Single-port surgery has seen almost as rapid an application as multiport laparoscopy during the early 1990s. Hopefully, we will learn from our predecessors to apply the dictums of safety and science as we move forward with this new technique to ensure adequate adoption and successful outcomes with limited errors and concerns along the way.

Reduced port surgery: an economical, ecological, educational, and efficient approach to development of single port access surgery.

There has been an emergence of reduced port techniques for laparoscopic surgery over the past three years. Although growing in presentations and papers, few scientific studies have yet to be published demonstrating benefits and risks of these techniques. In particular, very little is mentioned regarding the increased costs. This brings to the forefront the concept that the development of new surgical techniques should adhere to safe standards of surgery and undergo continued evaluation during development to ensure they maintain safety, and are able to be reproduced by our colleagues. Evaluation also needs to focus on costs, both economical and ecological. A review of our first three years experience of single port access surgery has been done. Costs in terms of both the potential economic and environmental impact have also been evaluated as compared with multiport procedures. In the first 36 months of this evolving technique, we were able to mimic multiport procedures with similar results. The costs of single port access are less than comparable multiport procedures, both in terms of dollars as well as medical waste. We are able to now offer "proof of concept" of a novel reduced port procedure from four important aspects in the development of new surgical techniques. We demonstrate comparable results in terms of outcomes and safety, improvement in financial and environmental costs, as well as showing initial success with training and application of the procedure by our colleagues.

Initial surgeon training for single port access surgery: our first year experience.

BACKGROUND: We have developed a single port access (SPA) surgical technique that allows for procedures to be done through a single umbilical port incision <20 mm in length. For a new approach to be universally beneficial, it needs to be easily learned and applied. METHODS: Single port access abdominal procedures are performed through one umbilical incision where skin and soft tissue flaps are raised from the underlying fascia to allow insertion of up to 4 instruments. Fifty surgeons with varying degrees of laparoscopic training participated in SPA training programs at Drexel University to learn and apply the SPA technique through participation in an animate (porcine) laboratory. RESULTS: All surgeons successfully performed the SPA access technique without difficulty and completed the cholecystectomy in <55 minutes (average, 42). Eight surgeons successfully performed placement of a cholangiogram catheter. All recognized the value of a formal training symposium to learn SPA techniques before performing SPA procedures in their practice. CONCLUSIONS: The SPA technique has been successfully shown to be an approach that is easily learned and accomplished. We believe this is a necessary and important bridge towards proficiency in performing SPA procedures in clinical patients.

Single port access (SPA) splenectomy.

INTRODUCTION: Over the last decade, laparoscopic splenectomy has become the standard of care for spleen removal. Elimination of a large incision and difficult exposure has decreased postoperative morbidity and length of stay. Single port access (SPA) surgery was developed as an alternative to traditional multiport laparoscopy, potentially exploiting the already proven benefits of minimally invasive surgery. We apply the SPA technique to splenectomy via a single umbilical incision. METHODS: SPA splenectomy was performed in a 36-year-old male for staging. The single-port access technique was used to gain abdominal entry. Exposure, dissection, and removal were performed via a single incision within the umbilicus. The final incision was extended for removal of a complete specimen for pathologic evaluation. RESULTS: Splenic mobilization and control of the short gastrics was successfully performed via a single umbilical incision. The final incision was extended inferiorly for en bloc organ removal. Follow-up at 18 months revealed a well-healed incision with no signs of hernia formation. CONCLUSIONS: The single-port access technique has been successfully applied to splenectomy as an available alternative to multiport laparoscopic splenectomy. Use of standard instrumentation and trocars maintains costs and familiarity of the procedure. Exposure, visualization, and dissection are the same as in standard laparoscopy. SPA surgery may be more ergonomically pleasing to the surgeon and offer patient benefits, such as faster recovery and decreased adhesion formation in the long term.

Reduced-port surgery: preservation of the critical view in single-port-access cholecystectomy.

BACKGROUND: Over the past 3 years, minimal-access surgery has seen movement toward single-port-access (SPA) surgery. Since its inception in the spring of 2007, a number of differing approaches and technologies for reduced-port surgery have become available to move the field toward "scarless" surgery. As with any advance, a cautious eye needs to observe changes with respect to the risks and benefits of new procedures or devices. Although the adoption of reduced-port techniques in cholecystectomy may move the field of surgery forward, there is a need to ensure that basic tenets of safety are not left behind. In cholecystectomy, one of the gold standards for safety is preservation of the critical view of safety during cystic duct dissection and transection. METHODS: Early in the development of SPA surgery, a standardized procedure was sought that could be extended safely to laparoscopic surgeons. With this ideal in mind, the technique of SPA cholecystectomy was evaluated early. Deeming exposure to be critical, specifically the view of the cystic-to-common duct relationship beneath the liver, the authors aimed to evaluate whether this critical view of safety can be maintained during the procedure and before the cystic port is clipped and transected. To determine reproducibility, the authors did a simple comparison of their initial 10 two-instrument SPA cholecystectomies with their subsequent 10 three-instrument cholecystectomies by reviewing the videos of each case. RESULTS: The authors' review confirmed that the critical view of safety was obtained in all the three-instrument cases but was difficult to obtain in the two-instrument procedures. In addition, they were able to demonstrate the critical angle of clip placement in all three-instrument cases. CONCLUSION: The authors present their initial results in an attempt to demonstrate that as new procedures develop, there is a need to ascertain their safety and adherence to underlying principles already established before advancing them further at the risk of compromise and complication.

Single-port-access (SPA) cholecystectomy: a multi-institutional report of the first 297 cases.

BACKGROUND: An important aspect of a new surgical technique is whether it can be performed by other surgeons in other institutions. The authors report the first 297 cases in a multi-institutional and multinational review of laparoscopic cholecystectomy performed via a single portal of entry. METHODS: Data were collected retrospectively for the initial patients undergoing single-port cholecystectomy by 13 surgeons who performed these procedures in their institutions after training by the authors. The review included operative time, blood loss, incision length, length of hospital stay (LOS), necessary additional trocars, and other parameters important to cholecystectomy. A database of all the single-port-access (SPA) surgeries performed by the surgeons included demographic and procedural details, LOS, complications, and initial follow-up data. RESULTS: To date, 297 single-port cholecystectomies have been performed for a variety of diagnoses, primarily cholelithiasis. The average operative time was 71 min, and the average LOS was 1-2 days. The average blood loss was minimal. The use of additional port sites outside the umbilicus occurred in 34 of the cases. Of the 35 intraoperative cholangiograms performed, 34 were successful. No significant complications occurred except for seromas and minor postoperative wound infections. These results are comparable with those for standard multiport cholecystectomy. In addition, no access site hernias (ASH) occurred. CONCLUSIONS: The findings demonstrate that SPA surgery is an alternative to multiport laparoscopy with fewer scars and better cosmesis. One factor affecting the rate for adoption of SPA surgery among other surgeons is the reproducibility of this new procedure. Although this study had insufficient data to determine fully the benefits of SPA surgery, the feasibility of this procedure with safe, acceptable results was demonstrated in this initial large series across multinational institutions.

Single port access (SPA) surgery--a 24-month experience.

INTRODUCTION: In April 2007, we performed our first single port access (SPA) surgical procedure. Beginning with simple procedures, we progressed to more complex procedures employing modifications of the initial technique. METHODS: Maintaining our abdominal entry technique through a single incision, typically umbilical, we have now successfully performed cholecystectomies, colon resections, small bowel procedures, liver biopsy, splenectomy, adrenalectomy, and surgery of the gastroesophageal junction. RESULTS: Two procedures have required additional port sites, none has employed transabdominal sutures, and <5% of all procedures have required articulation. Immediate follow-up demonstrates safe completion of multiple procedures with acceptable outcomes of blood loss and hospital stay. Although initial operative times are extended, a decrease is seen following a learning curve. At 2-year follow-up, two hernias developed at the extended incision for colon extraction. DISCUSSION AND CONCLUSION: With initial procedures performed in April 2007, we now report 24-month follow-up of a novel laparoscopic approach utilizing standard instrumentation. We demonstrate that SPA surgery is an alternative to multiport procedures with proposed initial benefits of decreased number of incisions and improved cosmesis for the patient. Long-term prospective randomized large case series will be necessary to assess pain, recovery, and hernia formation proving advantages, if any, over multiport laparoscopy.

Single Port Access (SPA) laparoscopic ventral hernia repair: initial report of 30 cases.

BACKGROUND: Laparoscopic ventral hernia repair has been demonstrated to be an acceptable and successful technique. Aside from similar, albeit fewer, complications compared to open hernia repair, the laparoscopic technique has the additional complication of port site hernia to its follow-up criteria. Our initial experience with reduced port surgery in hernias was described as a two-port one-stitch repair technique in 2002. We initially applied our Single Port Access (SPA) technique to ventral hernia repairs and reported it at the American Hernia Society meeting in 2008. Now we present the first 30 cases, some with 6-24-month follow-up. METHODS: The charts of 30 patients undergoing surgery for primary and recurrent ventral hernias employing the SPA technique were reviewed. The SPA technique was applied through a 1.0-1.6-cm incision remote from and lateral to the hernia location in the abdominal wall. Polypropylene-based coated mesh and non-fascial fixation were used in all cases. RESULTS: All procedures were completed via the SPA technique. Operative time, length of stay, and estimated blood loss were acceptable. The size of mesh placed ranged from 81 to 500 cm(2). Postoperative seromas were observed and all resolved spontaneously. There have been no wound infections or port site hernias during the 6-24-month follow-up period. There have been no recurrent hernias at the primary site. CONCLUSION: We have successfully demonstrated the applicability of Single Port Access surgery for ventral hernia repair. In our initial series we performed this procedure on smaller hernias but have now begun applying it to larger repairs.

Single Port Access (SPA™) Minimal Access Surgery Through a Single Incision.

The practice of surgical techniques is constantly improving and evolving. In the last two decades, minimally invasive surgery has gained widespread acceptance. Virtually all procedures can now be performed laparoscopically. This trend not only provides better cosmesis, but offers decreased recovery times as well. The initial trend from open to laparoscopic surgery was to use smaller incisions. The natural continuation of this is to now decrease the number of incisions necessary to perform minimal access surgery. To this end, the authors have seen a constantly evolving stream of technology and instrumentation in laparoscopy. New venues, such as robotics and Natural Orifice. Transluminal Endoscopic Surgery (NOTES), have developed as well. As part of this evolution, the authors developed Single Port Access (SPA™) surgery in April 2007 as a novel and innovative platform of minimal access surgery. Its acceptance through our training programs, as well as the subsequent development of modified Single Port techniques, demonstrates the potential to develop a new platform of minimal access surgery. The SPA™ technique is a method of abdominal entry for a wide spectrum of laparoscopic procedures performed by multiple surgical specialties. Using the access techniques we developed, the authors have performed nearly 200 general surgical and gynecologic procedures through a single incision, often <2 cm in length and hidden within the umbilicus. In addition, the development of SPA™ surgery has been focused on using current and standard instrumentation, as well as currently practiced surgical techniques already familiar to surgeons in standard multiport laparoscopy. The "Independence of Motion" attained in this access technique, without the need for any new access or operative devices, allows up to four instruments to be place through a single incision<2 cm in length. We have striven to maintain safety principles of multiport laparoscopy, as well, and have continued to improve the technique to increase the availability and broad application of SPA™ surgery. Out technique and its application, across a broad range of surgical procedures and surgical specialties, are presented herein.

Single port access (SPA) cholecystectomy: a completely transumbilical approach.

We have seen substantial changes in minimally invasive surgery since its development in the early 1900s. Over the past 10 years, the addition of natural orifice transluminal endoscopic surgery and robotics has turned our attention to improved cosmesis and advancements in instrumentation. We have developed a new technique-single port access (SPA) surgery-and have applied it to the cholecystectomy. In this paper, we present and review the application of this access technique to the first 5 consecutive patients that underwent an SPA cholecystectomy. All 5 patients were female, with an average age of 45 years and an average weight of 172 pounds. Indications included biliary dyskinesia and symptomatic cholelithiasis. Average operative time was 121 minutes in these initial 5 cases. All but 1 patient was discharged in 24 hours. At 6 months, no umbilical hernias were observed. This new technique allows for a complete cholecystectomy to be performed entirely through the umbilicus without the need for additional retraction sites or transabdominal sutures. This procedure utilizes the same basic technique of the laparoscopic cholecystectomy already employed by general surgeons. Therefore, the SPA cholecystectomy can be readily learned and performed by many surgeons without the need for expensive or experimental equipment. Using a single portal of entry to the abdominal cavity, the umbilicus, cosmesis, and scar reduction is achieved.

Single Port Access (SPA) gastrostomy tube in patients unable to receive percutaneous endoscopic gastrostomy placement.

BACKGROUND: Access procedures for alimentation have been performed both endoscopically and surgically. In those patients in whom endoscopic tubes cannot be placed, the minimally invasive approach is a viable alternative. To minimize incisions and their sequelae, we have developed a single port access (SPA) technique in which minimal access surgery can be done through one portal of entry, often the umbilicus. METHODS: We have used the SPA technique to place gastric feeding tubes in patients who are not candidates for PEG tubes due to supraglottic stenosis. We reviewed our experience in the first five procedures we performed. RESULTS: In all five patients a gastrostomy tube was placed laparoscopically via an umbilical incision and a left-upper-quadrant tube insertion point. Mean operative time was 44 min. All patients began tube feeds on postoperative day 1. CONCLUSION: We present the first series of five SPA gastric tube placements, offering a viable alternative to PEG or open placement.