Safety and Feasibility of Single-Port Robotic-Assisted Nipple-Sparing Mastectomy.

Importance: Robotic-assisted nipple-sparing mastectomies with multiport robots have been described in the US since 2015; however, significant hurdles to multiport robotic surgery exist in breast surgery. Objective: To demonstrate that the single-port da Vinci SP (Intuitive Surgical) robotic system is feasible in patients undergoing robotic nipple-sparing mastectomy (rNSM). Design, Setting, and Participants: An initial case series of 20 patients at a large university hospital underwent bilateral single-port robotic nipple-sparing mastectomies (SPrNSM) with tissue expander reconstruction from February 1, 2020, through January 4, 2023. Participants included women who met surgical criteria for nipple-sparing mastectomies, per standard of care. Intervention: Surgery using a single-port robot and the surgical technique of the authors. Main Outcomes and Measures: Age, indication, body mass index, breast size, operative time, conversion to open surgery, systemic complications, postoperative skin necrosis, and reported skin and nipple areolar complex (NAC) sensation. Results: Twenty women aged 29 to 63 years (median, 40 years) underwent bilateral SPrNSM. Eleven patients completed prophylactic surgery due to a high risk for breast cancer (more than 20% lifetime risk) and 9 patients had breast cancer. Breast size ranged from A through D cup with median B cup and a body mass index range of 19.7 through 27.8 (median 24.4). The total duration of the procedure from incision to skin closure for both sides ranged from 205 minutes to 351 minutes (median, 277). The median robotic time for bilateral SPrNSM was 116 minutes and varied by cup size (A cup, 95 minutes; B cup, 140 minutes; C cup, 118 minutes; D cup, 114 minutes) with no inflection point in learning curve. No cases were converted to open and no immediate complications, such as hematoma, positive margins, or recurrence, were seen. In the first 10 patients prior to routine sensation testing, 20 resected breasts had measurable NAC sensation at a range from 4 to 36 months post-index resection (65%). In the second 10 patients of the cohort, measurable NAC was preserved in 13 of 20 resected breasts 2 weeks following the index operation (65%). Conclusion and Relevance: In this case series, SPrNSM with immediate reconstruction was feasible and performed safely by an experienced breast surgeon with limited previous robotic training. Further studies confirming the preliminary data demonstrating improved NAC and skin sensation following SPrNSM are warranted. Trial Registration: ClinicalTrials.gov Identifier: NCT05245812.

Educational Experience Impacts Wellness More than Hours Worked.

OBJECTIVE: The Accreditation Council for Graduate Medical Education has focused its interests on resident wellbeing and the clinical work environment in recent years. Concerns regarding both duty hours as well as service obligations versus education resulted in programs nationwide receiving citations, including ours. This study aimed to evaluate the impact of those 2 factors on surgical residents' general wellbeing, hypothesizing that service obligations would be a stronger predictor. DESIGN: We have previously reported on the use of a "Fuel Gauge" tool developed at our institution for monitoring resident wellbeing. We performed a retrospective comparison of prospectively collected cross-sectional survey data comparing the Fuel Gauge to a bimonthly "Service Versus Education" (SVE) report. This report used similar scaling and allowed residents to provide feedback on the balance of the educational quality of their current rotation in comparison to their perception of service obligation. Pearson's correlation was then used to compare those scores with duty hour logs to determine if a relationship could be identified between the 3 measurements. SETTING: Academic institution of the University of Texas Southwestern in Dallas, Texas. PARTICIPANTS: Active general surgery residents (n = 73). RESULTS: During the study period, 73 residents filled out both a Fuel Gauge assessment and a SVE assessment at least once, with 273 complete data points available for analysis. Our program's Fuel Gauge median was 4, and our program's median SVE score was 4. Fuel Gauge assessment scores demonstrated a moderate positive correlation with SVE (r = 0.65, p < 0.001), while only a weakly negative association with increasing hours worked (r = -0.15, p = 0.015). SVE also demonstrated a weak negative correlation with hours logged (r = -0.225, p = 0.001). CONCLUSIONS: While the Accreditation Council for Graduate Medical Education recognizes that multiple factors contribute to resident wellbeing issues, early efforts were focused on limiting excessive duty hours. Examining our institutional data regarding the previously understudied factor of SVE, we indeed found a stronger correlation with resident perception of low educational value rather than excessive work hours contributing to lower Fuel Gauge scores. These data, if verified, should guide program directors in identifying other institutional factors that may more strongly contribute to their own culture of resident wellness.

Laparoscopic Ambidexterity in Left-Handed Trainees.

INTRODUCTION: There is a paucity of objective data about the advantages or disadvantages of handedness in surgery. Given the need for ambidexterity in laparoscopic surgery, our study aimed to identify the patterns in handedness and performance on basic laparoscopic tasks. METHODS: A retrospective analysis of intern laparoscopic performance on bimanual tasks was assessed for delta time (differences in task time between the dominant and nondominant hand) between left-hand and right-hand dominant interns. RESULTS: Data were analyzed for 16 residents. 25% were left-handed dominant (4/16) and 75% were right-handed dominant (12/16). Of the left-handed surgeons, 75% (3/4) operated primarily with their right hand. There was a significant difference between the time to task completion in Task 2 of left-handed and right-handed residents with median (IQR) time 94 s (90.25-97) and 127 s (104.25-128.5), respectively (P value = 0.02). No significant difference was seen between left-handed and right-handed residents on Task 1 (50 s versus 49 s) and Task 3 (51 s versus 59.5 s). In all three tasks, however, left-handed dominant residents had smaller variability (IQR 4.5-8 s versus 7-24.25 s) and significantly shorter delta times. CONCLUSIONS: Although true ambidexterity is rare, the ability to be facile with both hands is crucial for laparoscopic surgery. Our data show that variability in performance between the dominant hand and nondominant hand was remarkably smaller for left-hand dominant residents. This remains true despite the majority learning to operate with their nondominant hand. These data demonstrate a possible advantage to being left-hand dominant and may lead to further insights into variations of skill acquisition and improved curriculum development.

Creating a Proficiency-based Remote Laparoscopic Skills Curriculum for the COVID-19 Era.

OBJECTIVE: Social distancing restrictions due to COVID-19 challenged our ability to educate incoming surgery interns who depend on early simulation training for basic skill acquisition. This study aimed to create a proficiency-based laparoscopic skills curriculum using remote learning. DESIGN: Content experts designed 5 surgical tasks to address hand-eye coordination, depth perception, and precision cutting. A scoring formula was used to measure performance: cutoff time - completion time - (K × errors) = score; the constant K was determined for each task. As a benchmark for proficiency, a fellowship-trained laparoscopic surgeon performed 3 consecutive repetitions of each task; proficiency was defined as the surgeon's mean score minus 2 standard deviations. To train remotely, PGY1 surgery residents (n = 29) were each issued a donated portable laparoscopic training box, task explanations, and score sheets. Remote training included submitting a pre-test video, self-training to proficiency, and submitting a post-test video. Construct validity (expert vs. trainee pre-tests) and skill acquisition (trainee pre-tests vs. post-tests) were compared using a Wilcoxon test (median [IQR] reported). SETTING: The University of Texas Southwestern Medical Center in Dallas, Texas PARTICIPANTS: Surgery interns RESULTS: Expert and trainee pre-test performance was significantly different for all tasks, supporting construct validity. One trainee was proficient at pre-test. After 1 month of self-training, 7 additional residents achieved proficiency on all 5 tasks after 2-18 repetitions; trainee post-test scores were significantly improved versus pre-test on all tasks (p = 0.01). CONCLUSIONS: This proficiency-based curriculum demonstrated construct validity, was feasible as a remote teaching option, and resulted in significant skill acquisition. The remote format, including video-based performance assessment, facilitates effective at-home learning and may allow additional innovations such as video-based coaching for more advanced curricula.

Erector spinae plane block versus thoracic paravertebral block for pain management after total bilateral mastectomies.

This prospectively designed, clinical quality improvement project compared pain scores and opioid consumption between ultrasound-guided, erector spinae plane blocks (ESPB) and thoracic paravertebral blocks (PVB) in patients undergoing total bilateral mastectomies without reconstruction. Twenty-five patients were included in an enhanced recovery pathway and received an ESPB on one side and a PVB on the contralateral side. Numeric rating scores at rest and with movement for each side were recorded in the recovery room at 2, 6, 12, 24, and 48 hours and on days 3 to 7. There were no significant differences in the resting or movement-evoked pain scores between sides receiving ESPB or PVB at any time point up to day 7 after surgery. Both ESPB and PVB confer equal analgesic effects in patients undergoing mastectomies. ESPB provides an alternative to PVB in reducing postoperative pain in patients undergoing mastectomy as part of an enhanced recovery pathway.

The Impact of COVID-19 on Surgical Education.

BACKGROUND: At the onset of social distancing, our general surgery residency transitioned its educational curriculum to an entirely virtual format with no gaps in conference offerings. The aim of this study is to examine the feasibility of our evolution to a virtual format and report program attitudes toward the changes. METHODS: On March 15, 2020, due to the coronavirus disease (COVID-19) our institution restricted mass gatherings. We immediately transitioned all lectures to a virtual platform. The cancellation of elective surgeries in April 2020 then created the need for augmented resident education opportunities. We responded by creating additional lectures and implementing a daily conference itinerary. To evaluate the success of the changes and inform the development of future curriculum, we surveyed residents and faculty regarding the changes. Classes and faculty answers were compared for perception of value of the online format. RESULTS: Pre-COVID-19, residency-wide educational offerings were concentrated to one half-day per week. Once restrictions were in place, our educational opportunities were expanded to a daily schedule and averaged 16.5 hours/week during April. Overall, 41/63 residents and 25/94 faculty completed the survey. The majority of residents reported an increased ability (56%) or similar ability (34.1%) to attend virtual conferences while 9.9% indicated a decrease. Faculty responses indicated similar effects (64% increased, 32% similar, 4% decreased). PGY-1 residents rated the changes negatively compared to other trainees and faculty. PGY-2 residents reported neutral views and all other trainees and faculty believed the changes positively affected educational value. Comments from PGY1 and 2 residents revealed they could not focus on virtual conferences as it was not "protected time" in a classroom and that they felt responsible for patient care during virtual lectures. A majority of both residents (61%) and faculty (84%) reported they would prefer to continue virtual conferences in the future. CONCLUSIONS: The necessity for adapting our academic offerings during the COVID-19 era has afforded our program the opportunity to recognize the feasibility of virtual platforms and expand our educational offerings. The majority of participants report stable to improved attendance and educational value. Virtual lectures should still be considered protected time in order to maximize the experience for junior residents.

Assessing quality and resources during campus-wide simulation integration.

INTRODUCTION: Our simulation center, supported by four departments (Surgery, OB/GYN, Urology, and Anesthesiology), is accredited as a comprehensive Accredited Educational Institute (AEI) and is now expanding to accommodate all departments on campus. METHODS: A 61-point questionnaire was administered to 44 stakeholders, representing all of UME and GME. Data were compared for AEI vs. non-AEI activities. RESULTS: Responses were collected from all 44 groups (100% response rate). Overall, 43 simulation activities were hosted within the AEI and 40 were hosted by non-AEI stakeholders. AEI activities were more likely to be mandatory (93% vs. 75%, p = 0.02), have written learning objectives (79% vs 43%, p < 0.001), and use validated assessment metrics (33% vs. 13%, p = 0.03). CONCLUSION: These data suggest that the AEI courses are more robust in terms of structured learning and assessment compared to non-AEI courses. Campus-wide application of uniform quality standards is anticipated to require significant faculty, course, and program development.

Male Breast Cancer as a Second Primary Cancer: Increased Risk Following Lymphoma.

BACKGROUND: Male breast cancer (MBC) as a second primary cancer (SPC) has a known association with prior MBC. However, its association with non-breast index malignancies, relative to population risk, has not been previously reported. MATERIALS AND METHODS: Using Surveillance, Epidemiology, and End Results program (9 catchment area) data, we identified MBCs diagnosed from 1973-2012 as their SPC. Information regarding the index malignancy was also obtained. Standardized incidence ratios (SIR) of MBC as SPC were estimated, along with incidence rates and trends. Kaplan-Meier curves were used to estimate survival. RESULTS: Over a 38-year period, 464 MBCs were identified as SPC. The most common index malignancies were breast (SIR 30.86, 95% confidence interval [CI] 21.50-42.92, p < .001), lymphoma (SIR 1.58, 95% CI 1.08-2.22, p = .014), melanoma (SIR 1.26, 95% CI 0.80-1.89), urinary (SIR 1.05, 95% CI 0.74-1.43), colorectal (SIR 0.94, 95% CI 0.69-1.24), and prostate (SIR 0.93 95% CI 0.81-1.07). Apart from the known association with prior breast cancer, the only significant association was with lymphoma as an index cancer, although not significant with a Bonferroni correction. From 1975-2012, incidence of breast cancer as a first cancer increased at an annual percentage change of 1.3% while breast cancer as a SPC increased at 4.7% (both p values < .001). CONCLUSION: Male breast cancer as a SPC has increased markedly over 4 decades. Men with a history of lymphoma may experience higher-than-expected rates of breast SPC. These observations warrant further research, and suggest possible etiologic connections with disease biology, prior therapy, or genetics. IMPLICATIONS FOR PRACTICE: This study reports that men are presenting more frequently to the clinic with breast cancer, both as an initial cancer and as a second cancer following an earlier malignancy. We also report the novel observation that men who survive lymphoma are at increased risk of developing a subsequent breast cancer. Further work is needed to better understand possible treatment or biologic causes of this association. More immediately, these findings suggest the need for heightened vigilance for male breast cancer overall and, in particular, for male lymphoma survivors.

Recombinant human factor VIIa-induced alterations in tissue factor and thrombomodulin in patients with advanced liver cirrhosis.

BACKGROUND: Recombinant human factor VIIa (rhFVIIa) is used to treat hemophilia and occasionally individuals with liver disease. The aim of the present study was to investigate the consequences of rhFVIIa in individuals with advanced liver disease in an attempt to understand the mechanism of action of rhFVIIa in this unique population. METHODS: Levels of plasma tissue factor, plasminogen activator inhibitor-1, tissue factor pathway inhibitor, fibrin split products, D-dimers and free thrombomodulin were measured following the administration of rhFVIIa in 17 subjects. The results were compared to normal controls. RESULTS: The prothrombin time declined from 20.2 +/- 2.8 s to 14.3 +/- 3.9 s (P < 0.01). No change in the activated partial thromboplastin time occurred. A 15.6% reduction in thrombomodulin was observed (P < 0.05). A mean 75.2% reduction in plasma tissue factor occurred (P < 0.01). Tissue factor pathway inhibitor levels declined to less than the control value (P < 0.05). No changes in plasminogen activator inhibitor-1, fibrin split products or D-dimer levels occurred. CONCLUSIONS: These data demonstrate that rhFVIIa administration to individuals with liver disease results in (i) a transient improvement in the prothrombin time; (ii) no change in the activated partial thromboplastin time; and (iii) a marked reduction in the levels of thrombomodulin and tissue factor. These data suggest that rhFVIIa binds tissue factor and enhances tissue factor and thrombomodulin clearance from the circulation.