Effect of video-based self-reflection on intraoperative skills: A pilot randomized controlled trial.

BACKGROUND: The value of video-based self-assessment in enhancing surgical skills is uncertain. This study investigates the feasibility and estimates sample size for a full-scale randomized controlled trial to evaluate the effectiveness of video-based self-assessment to improve surgical performance of laparoscopic cholecystectomy in trainees. METHODS: This parallel pilot randomized controlled trial included general surgery trainees performing supervised laparoscopic cholecystectomy randomized 1:1 to control (traditional intraoperative teaching) or intervention group (traditional teaching plus video-based self-assessment). Operative performance was measured by the attending surgeon blinded to group assignment at the time of surgery using standardized assessment tools (Global Operative Assessment of Laparoscopic Skills and Operative Performance Rating System). The intervention group had access to their video recordings on a web-based platform for review and self-assessment using the same instruments. The primary outcome for the estimation of sample size was the difference in faculty-assessed final operative performance (third submitted case). Feasibility criteria included >85% participation, >85% adherence to case submission and >85% completion of self-assessment. RESULTS: Of 37 eligible trainees approached, 32 consented and were randomized (86%). There were 16 in the intervention group, 15 in the control group (55% male, 55% junior trainees), and 1 was excluded for protocol violation. Twenty-four (75%) of participants submitted 3 cases. Thirteen trainees (81%) accessed the platform and completed 26 (63.2%) case self-assessments. Fifty-five trainees per arm will be needed to power a full-scale laparoscopic cholecystectomy with Global Operative Assessment of Laparoscopic Skills and 130 trainees per arm with Operative Performance Rating System as the assessment tool. CONCLUSION: This pilot study contributes important data to inform the design of an adequately powered randomized controlled trial of video-based self-assessment to improve trainee performance of laparoscopic cholecystectomy. Although a priori trial feasibility criteria were not achieved, automated video capture and storage could significantly improve adherence in future trials.

What are essential laparoscopic skills these days? Results of the SAGES Fundamentals of Laparoscopic Surgery (FLS) Committee technical skills survey.

INTRODUCTION: The Fundamentals of Laparoscopic Surgery (FLS) program tests basic knowledge and skills required to perform laparoscopic surgery. Educational experiences in laparoscopic training and development of associated competencies have evolved since FLS inception, making it important to review the definition of fundamental laparoscopic skills. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) assigned an FLS Technical Skills Working Group to characterize technical skills used in basic laparoscopic surgery in current practice contexts and their possible application to future FLS tests. METHODS: A group of subject matter experts defined an inventory of 65 laparoscopic skills using a Nominal Group Technique. From these, a survey was developed rating these items for importance, frequency of use, and priority for testing for FLS certification. This survey was distributed to SAGES members, recent recipients of FLS certification, and members of the Association of Program Directors in Surgery (APDS). Results were collected using a secure web-based survey platform. RESULTS: Complete data were available for 1742 surveys. Of these, 1143 comprised results for post-residency participants who performed advanced procedures. Seventeen competencies were identified for FLS testing prioritization by determining the proportion of respondents who identified them of highest priority, at median (50th percentile) of the maximum survey scale rating. These included basic peritoneal access, laparoscope and instrument use, tissue manipulation, and specific problem management skills. Sixteen could be used to show appropriateness of the domain construct by confirmatory factor analysis. Of these 8 could be characterized as manipulative tasks. Of these 5 mapped to current FLS tasks. CONCLUSIONS: This survey-identified competencies, some of which are currently assessed in FLS, with a high level of priority for testing. Further work is needed to determine if this should prompt consideration of changes or additions to the FLS technical skills test component.

A Video-Based Assessment Tool to Measure Intraoperative Laparoscopic Suturing Using a Modified Script Concordance Methodology.

OBJECTIVES: Laparoscopic suturing (LS) is a challenging laparoscopic skill to teach. Its complexity and nuances are not modeled or measured in current simulation and assessment platforms.The script concordance test (SCT) is used to assess clinical reasoning.The purpose of this study is to provide evidence for validity of this novel SCT based online assessment for LS skills. DESIGN: We designed a video-based online SCT for LS using a cognitive task analysis and expert panelists.The CTA yielded 4 LS domains: needle handling (NH), tissue handling (TH), knot tying techniques (KT) and operative ergonomics (OE). Five-point scales with anchoring descriptors from -2 to +2 were used. Scoring was based on a modified SCT methodology. SETTING AND PARTICIPANTS: The test was administrated to 37 subjects (18 experts and 19 novices). There was no time limit given. A different expert group from the minimal invasive surgery (MIS) panelist were recruited. Experts were defined as surgeons and fellows with LS experience of >25 cases annually. Validity was assessed by comparing SCT scores of experienced and inexperienced surgeons. Cronbach's alpha was used to assess the internal consistency of the test. RESULTS: The survey started off with 47 questions in each of the following domains: 13 NH, 4 TH, 20 KT and 10 OE. Thirty-seven surgeons (18 experts and 19 inexperienced surgeons). Questions that demonstrated a large discrepancy among experts and panelists with a weighted score difference more than 40 were discarded (n = 20). One question was discarded because it received a 100% score from all participants. This yielded 26 remaining questions in the following domains: 8 NH, 2 TH, 11 KT and 5 OE. The test reliability level (Cronbach a) was 0.80. The mean score was 72 ± 9% and 63 ± 15% (p = 0.02) for experts and inexperienced surgeons, respectively. The mean time to complete the test was 21 minutes. CONCLUSION: This study provides validity evidence for a novel intraoperative LS assessment. The variability of responses between experts and panelists suggests that SCT may capture the clinical differences/surgeon preferences in performing LS intraoperatively.

Factors influencing surgeon well-being: qualitatively exploring the joy of surgery.

BACKGROUND: There has been considerable research into burnout but much less into how surgeons thrive and find joy. This study, conducted by the SAGES Reimagining the Practice of Surgery Task Force, explored factors influencing surgeon well-being, the eventual goal being translating findings into tangible changes to help restore the joy in surgery. METHODS: This was a qualitative, descriptive study. Purposive sampling ensured representation across ages, genders, ethnicities, practice types, and geographies. Semi-structured interviews were recorded and transcribed. We coded inductively, finalized the codebook by consensus, and then constructed a thematic network. Global themes formed our conclusions; organizing themes gave additional detail. Analysis was facilitated by NVivo. RESULTS: We interviewed 17 surgeons from the US and Canada. Total interview time was 15 hours. Our global and organizing themes were: Stressors (Work-life Integration, Administration-related Concerns, Time and Productivity Pressures, Operating Room Factors, and Lack of Respect). Satisfaction (Service, Challenge, Autonomy, Leadership, and Respect and Recognition). Support (Team, Personal Life, Leaders, and Institutions). Values (Professional and Personal). Suggestions (Individual, Practice, and System level). Values, stressors, and satisfaction influenced perspectives on support. Experiences of support shaped suggestions. All participants reported stressors and satisfiers. Surgeons at all stages enjoyed operating and being of service. Supports and suggestions included compensation and infrastructure, but human resources were most critical. To experience joy, surgeons needed high-functioning clinical teams, good leaders/mentors, and supportive family/social networks. CONCLUSIONS: Our results indicated organizations could (1) better understand surgeons' values, like autonomy; (2) provide more time for satisfiers, like patient relationship building; (3) minimize stressors, like time and financial pressures; and (4) at all levels focus on (4a) building teams and leaders and (4b) giving surgeons time and space for healthy family/social lives. Next steps include developing an assessment tool for individual institutions to build "joy improvement plans" and to inform surgical associations' advocacy efforts.

Defining Cognitive Competencies for Breast Augmentation Surgery.

BACKGROUND: Breast augmentation is the most performed aesthetic procedure in the United States yet one that surgical trainees have limited exposure to. This creates a lack of confidence in performing this key procedure among graduates. It is imperative to develop novel curricula and objective measures to standardize acquiring competency. OBJECTIVE: This qualitative study establishes various cognitive competencies and pitfalls in augmentation mammoplasty. METHODS: Using a priori established task analysis, literary sources and operative observations, a total of 20 cognitive vignettes were developed to conduct cognitive task analyses (CTA) for breast augmentation through semistructured interviews of experts. Interviews were itemized, and verbal data were recorded, transcribed verbatim, and thematically analyzed by reviewers. RESULTS: Eight experts were interviewed (median age 39 years, 87.5% males, with a median of 7 years in practice). A conceptual framework for breast augmentation was developed and divided into 5 operative stages containing 208 competencies and 41 pitfalls. Pitfalls were mapped to deficits in shared decision making, proper informed consent, prospective hemostasis, and awareness of anatomical landmarks and markings. CONCLUSIONS: This work provided an inclusive framework of cognitive competencies in breast augmentation surgery to facilitate their assessment. This model guides the analysis of other procedures to transfer cognitive competencies to learners. In a transition toward competency-based education, this provides a primer to assessments that include all aspects of a surgeon's skill set.

An argument-based validation study of the fundamentals of laparoscopic surgery (FLS) program.

BACKGROUND: The Fundamentals of Laparoscopy Surgery (FLS) program was launched over 15 years ago. Since then, there has been an exponential rise in advancements of laparoscopy and its uses. In response, we conducted an argument-based validation study of FLS. The purpose of this paper is to exemplify this approach to validation for surgical education researchers using FLS as an illustrative case. METHODS: The argument-based approach to validation involves three key actions: (1) developing interpretation and use arguments; (2) research; and (3) building a validity argument. Drawing from the validation study of FLS each step is exemplified. RESULTS: Qualitative and quantitative data sources from the FLS validity examination study provided evidence that both supported claims, but also generated backing for rebuttals. Some of the key findings were synthesized in a validity argument to illustrate its structure. DISCUSSION: The argument-based validation approach described numerous advantages over other validation approaches: (1) it is endorsed by the foundational documents in assessment and evaluation research; (2) its specific language of claims, inferences, warrants, assumptions and rebuttals provides a systematic and unified way to communicate both the processes and outcomes of validation; and (3) the use of logic reasoning in building the validity document clearly delineates the relationship between evidence and the inferences made to support desired uses and interpretations from assessments.

The entrustable professional activities of laparoscopic surgery: moving toward an integrated training model.

BACKGROUND: Entrustable Professional Activities (EPAs) provide the opportunity to integrate multiple competencies into meaningful units that facilitate curriculum development and assessment design. As part of the process of reviewing and enhancing the Fundamentals of Laparoscopic of Surgery (FLS) program, we used the concept of EPAs to create a framework of reference that articulates a contemporary definition of Laparoscopic Surgery (LS). METHODS: The framework of reference of LS was created with data gathered from a literature review and during series of educational retreats with subject matter experts (SMEs). Various activities were implemented during these retreats to develop the LS EPAs, their constitutive competencies, and related observable behaviors. RESULTS: Ten EPAs and associated competency descriptors (articulated as observable behaviors) specific to LS were identified. In addition, knowledge areas were associated to each EPA. DISCUSSION: A comprehensive list of EPAs for LS were identified. These EPAs will be used in the development and update of the FLS program. Further, they can be used to guide the development of curriculum, clinical teaching, and assessment in any surgical program with a laparoscopic training component. They are applicable to any level of training by defining the expected observable behaviors associated with a given level of expertise. These fundamental aspects of LS provide a common framework of reference across different surgical specialties.

Implementation of entrustable professional activities into fellowship council accredited programs: a pilot project.

OBJECTIVE: The Fellowship Council (FC) is transitioning to a competency-based medical education (CBME) model, including the introduction of Entrustable Professional Activities (EPAs) for training and assessment of Fellows. This study describes the implementation process employed by the FC during a ten-month pilot project and presents data regarding feasibility and perceived value. METHODS: The FC coordinated the development of EPAs in collaboration with the sponsoring societies for Advanced GI/MIS, Bariatrics, Foregut, Endoscopy and Hepatopancreaticobiliary (HPB) fellowships encompassing the preoperative, intraoperative, and postoperative phases of care for key competencies. Fifteen accredited fellowship programs participated in this project. The assessments were collected through a unique platform on the FC website. Programs were asked to convene a Clinical Competency Committee (CCC) on a quarterly basis. The pilot group met monthly to support and improve the process. An exit survey evaluated the perceived value of EPAs. RESULTS: The 15 participating programs included 18 fellows and 106 faculty. A total of 655 assessments were initiated with 429 (65%) completed. The average (SD) number of EPAs completed for each fellow was 24(18); range 0-72. Intraoperative EPAs were preferentially completed (71%). The average(SD) time for both the fellow and faculty to complete an EPA was 27(78) hours. Engagement increased from 39% of fellows completing at least one EPA in September to 72% in December and declining to 50% in May. Entrustment level increased from 6% of EPAs evaluated as "Practice Ready" in September to 75% in June. The exit survey was returned by 63% of faculty and 72% of fellows. Overall, 46% of fellows and 74% of program directors recommended full-scale implementation of the EPA framework. CONCLUSION: A competency-based assessment framework was developed by the FC and piloted in several programs. Participation was variable and required ongoing strategies to address barriers. The pilot project has prepared the FC to introduce CBME across all FC training programs.

Validity of video-based general and procedure-specific self-assessment tools for surgical trainees in laparoscopic cholecystectomy.

INTRODUCTION: Self-review of recorded surgical procedures offers new opportunities for trainees to extend technical learning outside the operating-room. Valid tools for self-assessment are required prior to evaluating the effectiveness of video-review in enhancing technical learning. Therefore, we aimed to contribute evidence regarding the validity of intraoperative performance assessment tools for video-based self-assessment by general surgery trainees when performing laparoscopic cholecystectomies. METHODS AND PROCEDURES: Using a web-based platform, general surgery trainees in a university-based residency program submitted recorded laparoscopic cholecystectomy procedures where they acted as the supervised primary surgeon. Attending surgeons measured operative performance at the time of surgery using general and procedure-specific assessment tools [Global Operative Assessment of Laparoscopic Skills (GOALS) and Operative Performance Rating System (OPRS), respectively] and entrustability level (O-SCORE). Trainees self-evaluated their performance from video-review using the same instruments. The validity of GOALS and OPRS for trainee self-assessment was investigated by testing the hypotheses that self-assessment scores correlate with (H1) expert assessment scores, (H2) O-SCORE, and (H3) procedure time and that (H4) self-assessment based on these instruments differentiates junior [postgraduate year (PGY) 1-3] and senior trainees (PGY 4-5), as well as (H5)simple [Visual Analogue Scale (VAS) ≤ 4] versus complex cases (VAS > 4). All hypotheses were based on previous literature, defined a priori, and were tested according to the COSMIN consensus on measurement properties. RESULTS: A total of 35 videos were submitted (45% female and 45% senior trainees) and self-assessed. Our data supported 2 out of 5 hypotheses (H1 and H4) for GOALS and 3 out of 5 hypotheses (H1, H4 and H5) for OPRS, for trainee self-assessment. CONCLUSIONS: OPRS, a procedure-specific assessment tool, was better able to differentiate between groups expected to have different levels of intraoperative performance, compared to GOALS, a general assessment tool. Given the interest in video-based learning, there is a need to further develop valid procedure-specific tools to support video-based self-assessment by trainees in a range of procedures.

Establishing validity evidence for device-assisted advanced laparoscopic suturing tasks using simulation.

BACKGROUND: Laparoscopic suturing (LS) is an essential technique required for a wide range of procedures, and it is one of the most challenging for surgical trainees to master. We designed and collected validity evidence for advanced LS tasks using an automated suturing device and evaluated the perceived educational value of the tasks. METHODS: This project was a multicentre prospective study involving McGill University, University of Toronto (UofT), and Louisiana State University (LSU) Health New Orleans. Novice (NS) and experienced (ES) surgeons performed suturing under tension (UT) and continuous suturing (CS) tasks. ES performed the tasks twice to establish proficiency benchmarks, and they were interviewed to develop formative feedback tools (FFT). Participants were assessed on completion time, error, Global Operative Assessment of Laparoscopic Skills (GOALS), and FFT. Data were analyzed using descriptive and inferential statistical methods. RESULTS: Twenty-seven participants (13 ES, 14 NS, median age 34 years; 85% male) completed the study. Eight were attending surgeons, 7 fellows, 4 PGY5, 5 PGY4, and 3 PGY3 (18 from McGill, 5 UofT, and 4 LSU). Comparing ES and NS, for UT task, ES had significantly greater task scores (570 [563-648] vs 323 [130-464], p value 0.00036) and GOALS scores (14 [13-16] vs 10 [8-12], p value 0.0038). Similarly, for CS, ES had significantly greater task scores (976 [959-1010] vs 785 [626-856], p value 0.00009) and GOALS scores (16 [12-17] vs 12.5 [8.25-15], p value 0.028). After FFTs were developed, comparing ES and NS, for both UT and CS tasks, ES had significantly greater FFT scores (UT 25 [24-26] vs 17 [14-20], p value 0.0016 and CS 30 [27-32] vs 22[17.2-25.8], p value 0.00061). CONCLUSION: In conclusion, preliminary validity evidence was provided for the tasks. Once further validity evidence is established, incorporating the tasks into the training curricula could improve trainee skills and help to meet the need for better advanced suturing models.

Teaching and Assessing Cognitive Competencies in Aesthetic and Plastic Surgery.

BACKGROUND: Cognition, part of surgical competence, employs forward planning, error prevention, and orchestration of technical skills. Thus, an understanding of mental processes used by experts throughout patient care is essential to teaching such competencies. The authors' study aimed to analyze and compare mental models of two distinct procedures in plastic surgery-breast augmentation and flexor tendon repair-to develop a framework to define cognitive competencies in plastic surgery aided by a review of the literature. METHODS: Based on data from a priori cognitive task analyses, literary sources, and field observations of breast augmentation surgery and flexor tendon repair, task lists were produced for each procedure. Two mental models were developed using fuzzy logic cognitive maps to visually illustrate and analyze cognitive processes used in either procedure. A comparison of the models aided by literature was used to define the cognitive competencies employed, identify differences in the decision-making process, and provide a guiding framework for understanding cognitive competencies. RESULTS: Five distinct cognitive competency domains were identified from the literature applicable to plastic surgery: situation awareness, decision-making, task management, leadership, and communication and teamwork. Differences in processes of decision-making utilized between an elective and a trauma setting were identified. A framework to map cognitive competencies within a generic mental model in surgical care was synthesized, and methods were suggested for training on such competencies. CONCLUSION: Cognitive competencies in different settings in plastic surgery are introduced using a comparative study of two mental models of distinct procedures to guide the teaching and assessment of such competencies.

The association between video-based assessment of intraoperative technical performance and patient outcomes: a systematic review.

BACKGROUND: Efforts to improve surgical safety and outcomes have traditionally placed little emphasis on intraoperative performance, partly due to difficulties in measurement. Video-based assessment (VBA) provides an opportunity for blinded and unbiased appraisal of surgeon performance. Therefore, we aimed to systematically review the existing literature on the association between intraoperative technical performance, measured using VBA, and patient outcomes. METHODS: Major databases (Medline, Embase, Cochrane Database, and Web of Science) were systematically searched for studies assessing the association of intraoperative technical performance measured by tools supported by validity evidence with short-term (≤ 30 days) and/or long-term postoperative outcomes. Study quality was assessed using the Newcastle-Ottawa Scale. Results were appraised descriptively as study heterogeneity precluded meta-analysis. RESULTS: A total of 11 observational studies were identified involving 8 different procedures in foregut/bariatric (n = 4), colorectal (n = 4), urologic (n = 2), and hepatobiliary surgery (n = 1). The number of surgeons assessed ranged from 1 to 34; patient sample size ranged from 47 to 10,242. High risk of bias was present in 5 of 8 studies assessing short-term outcomes and 2 of 6 studies assessing long-term outcomes. Short-term outcomes were reported in 8 studies (i.e., morbidity, mortality, and readmission), while 6 reported long-term outcomes (i.e., cancer outcomes, weight loss, and urinary continence). Better intraoperative performance was associated with fewer postoperative complications (6 of 7 studies), reoperations (3 of 4 studies), and readmissions (1 of 4 studies). Long-term outcomes were less commonly investigated, with mixed results. CONCLUSION: Current evidence supports an association between superior intraoperative technical performance measured using surgical videos and improved short-term postoperative outcomes. Intraoperative performance analysis using video-based assessment represents a promising approach to surgical quality-improvement.

Development of a simulation curriculum to teach and assess advanced laparoscopic suturing skills using telesimulation: a feasibility study.

BACKGROUND: Telesimulation helps overcome limitations in time and local expertise by eliminating the need for the learner and educator to be physically co-located, especially important during COVID-19. We investigated whether teaching advanced laparoscopic suturing (ALS) through telesimulation is feasible, effective, and leads to improved suturing in the operating room (OR). METHODS: In this prospective feasibility study, three previously developed 3D-printed ALS tasks were used: needle handling (NH), suturing under tension (UT), and continuous suturing (CS). General surgery residents (PGY4-5) underwent 1-month of telesimulation training, during which an expert educator at one site remotely trained residents at the other site over 2-3 teaching sessions. Trainees were assessed in the three tasks and in the OR at three time points: baseline(A1), control period(A2), and post-intervention(A3) and completed questionnaires regarding educational value and usability of telesimulation. Paired t-test was used to compare scores between the three assessment points. RESULTS: Six residents were included. Scores for UT improved significantly post-intervention A3(568 ± 60) when compared to baseline A1(416 ± 133) (p < 0.019). Similarly, scores for CS improved significantly post-intervention A3(756 ± 113) vs. baseline A1(539 ± 211) (p < 0.02). For intraoperative assessments, scores improved significantly post-intervention A3(21 ± 3) when compared to both A1(17 ± 4) (p < 0.018) and A2(18 ± 4) (p < 0.0008). All residents agreed that tasks were relevant to practice, helped improve technical competence, and adequately measured suturing skill. All residents found telesimulation easy to use, had strong educational value, and want the system to be incorporated into their training. CONCLUSION: The use of telesimulation for remotely training residents using ALS tasks was feasible and effective. Residents found value in training using the tasks and telesimulation system, and improved ALS skills in the OR. As the pandemic has caused a major structural shift in resident education, telesimulation can be an effective alternative to on-site simulation programs. Future research should focus on how telesimulation can be effectively incorporated into training programs.

Toward Competency-Based Training: To What Extent Are We Competency-Based?

BACKGROUND: Time-based training models in plastic surgery vary in exposure, resulting in low confidence levels among graduates. The evolution of postgraduate medical education into a competency-based model to address these issues requires an understanding of interventions described in the plastic surgery literature to identify gaps and guide creation of assessments to demonstrate competence. METHODS: A systematic search of the MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, PubMed, and Cochrane databases from inception until December of 2017 was conducted using search terms and synonyms of educational interventions reported in plastic surgery. Full texts were retrieved following filtering and data extracted were related to intervention design and execution, involvement of competency assessment, and educational objectives and alignment to Accreditation Council for Graduate Medical Education competencies and Royal College of Physicians and Surgeons of Canada Canadian Medical Education Directives for Specialists roles. Study quality was assessed using Kirkpatrick's levels of learning evaluation, validity evidence, and the Medical Education Research Study Quality Instrument score. RESULTS: Of the initial 4307 results, only 36 interventions met the inclusion criteria. Almost all interventions aligned to medical knowledge and patient care Accreditation Council for Graduate Medical Education competencies. One-fifth of the interventions involved no assessment of competency, whereas most displayed assessment at the level of design as opposed to outcomes. Quality assessment revealed low levels of learning evaluation and evidence of validity; the average Medical Education Research Study Quality Instrument score was 10.9 of 18. CONCLUSION: A systematic review of educational literature in plastic surgery was conducted to assess the quality of reported educational interventions, and to help guide creating tools that ensure competency acquirement among trainees.

S116: Impact of incisional negative pressure wound therapy on surgical site infection after complex incisional hernia repair: a retrospective matched cohort study.

INTRODUCTION: Incisional negative pressure wound therapy (iNPWT) may reduce surgical site infections (SSI), which can have devastating consequences after incisional hernia repair. Few comparative studies investigate the effectiveness of this wound management strategy in this population. The objective of this study is to determine the effect of iNPWT on the incidence of SSI after complex incisional hernia repair. METHODS: All adult patients undergoing open incisional hernia repair at a single center from 2016 to 2019 were reviewed. A commercial iNPWT dressing was used at the discretion of the surgeon. Patients were grouped by type of dressing; iNPWT and standard sterile dressings (SSD). Coarsened exact matching was used to create balanced cohorts for comparison using age, sex, American Society of Anesthesiologists classification, wound classification, and surgical urgency. The primary outcome was the composite incidence of superficial and deep SSI within 30 days. Secondary outcomes included non-infectious surgical site occurrences (SSO), overall complications, length of stay (LOS), emergency department visits, and readmission at 30 days. RESULTS: 134 patients underwent complex hernia repair, with 114 patients included after matching (34 iNPWT, 51 SSD). Composite incidence of superficial and deep SSI was 19.3% (11.8% vs. 27.5%, p = 0.107), with significantly lower rates of deep SSI in patients receiving iNPWT (2.9% vs. 17.6%, p = 0.045). After accounting for residual differences between groups, iNPWT was associated with decreased incidence of composite SSI (RR 0.36, 95% CI [0.16, 0.87]). Median LOS was longer in patients with iNPWT (7 vs. 5 days, p = 0.001). There were no differences in SSO, overall complications, readmission, or emergency department visits. CONCLUSION: In patients undergoing incisional hernia repair, the use of iNPWT was associated with a lower incidence of SSI at 30 days. Future studies should focus on cost effectiveness of iNPWT, its impact on long-term hernia recurrences, and the identification of patient selection criteria in this population.

Defining the key skills required to perform advanced laparoscopic procedures: a qualitative descriptive study.

BACKGROUND: Simulation is widely used to teach and assess fundamental laparoscopic skills; however, program directors have reported that current simulation programs do not meet the needs for trainees and surgeons learning advanced laparoscopic procedures (ALP). The purpose of our study was to identify the key skills required to perform ALP, to serve as the basis to establish an advanced laparoscopic skills training program. METHODS: Semi-structured interviews were conducted with attending surgeons, fellows, and senior residents in general surgery, gynaecology, and urology. The questions were developed through an iterative process using relevant literature, expert opinions, and in consultation with a qualitative researcher. Interviews were conducted in person, over the phone, or by videoconference, and inductive thematic analysis was performed. RESULTS: 25 interviews were conducted with 16 attending surgeons and 9 fellows/residents from 9 institutions in Canada and USA. Twenty-one skills were identified to be important when performing ALP. The skills most commonly described by faculty were the following : (a) suturing, (b) dissection, (c) procedural expertise, (d) retraction and exposure, and (e) familiarity with relevant anatomy as viewed through the laparoscope. The skills most commonly described by trainees were the following: (a) suturing, (b) dissection, (c) procedural expertise, (d) trocar positioning, and (e) patient factors. There was a large difference between the importance the faculty attributed to the 'Retraction and Exposure' skill compared to the trainees. CONCLUSION: This study identified key skills that are important when performing ALP. In order to address the current needs of trainees/surgeons learning ALP, this work provides the building blocks for the development of an advanced laparoscopic surgery simulation program.

Modern era surgical outcomes of elective and emergency giant paraesophageal hernia repair at a high-volume referral center.

INTRODUCTION: Repair of giant paraesophageal hernia (PEH) has historically been associated with significant morbidity and mortality such that elective repair is only offered to symptomatic patients. Recent reports suggest modern era outcomes have improved such that elective repair may now be safer than historically thought. Furthermore, the morbidity of emergency surgery may still be significant. These changes may have important implications for patient selection for elective repair. The objectives of this study were to determine and compare modern era surgical outcomes after elective and emergency repair of giant PEHs at a high-volume tertiary care center. METHODS: A retrospective review was conducted for all Type II-IV giant PEH repairs performed between 1 January 2012 and 31 December 2017. Type 1 hiatal hernias, fundoplication for reflux, and any co-surgery other than cholecystectomy were excluded from the final analysis. Baseline patient demographics, operative details, postoperative complications within 30 days and in-hospital or 30-day mortality were tabulated from the electronic medical record. Data were reported as median (interquartile range) unless otherwise specified. RESULTS: A total of 352 cases were reviewed, of which 204 met inclusion criteria (18 emergency, 186 elective). Eight had Type II PEH, 146 had Type III, and 50 had Type IV. Median length of stay was shorter in the elective group [1 (1) day elective vs. 5 (7) days emergency, p < 0.0001], and emergency patients were less likely to return directly to their original residence at discharge (13, 72% emergency vs 185, 99.4% elective, p < 0.0001). There were significantly more major complications (Clavien-Dindo score ≥ 3) in the emergency group (5, 28% emergency vs. 10, 5% elective, p = 0.005). There were no perioperative deaths in either group. Morbidity and mortality in both groups were less than historically reported. CONCLUSIONS: Informed consent discussions and patient selection for repair of giant PEHs should reflect modern era and institution-specific outcomes.

Is there a gender bias in the advancement to SAGES leadership?

BACKGROUND: The proportion of women in surgery has risen significantly yet there remains gender discrepancies in upper leadership positions in academia. Specialty societies play an important role in academic advancement but the progression of women in surgical societies has not been studied. The purpose of this study was to determine if there are gender differences in advancement within the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) leadership. METHODS: A retrospective audit of all SAGES committee members (CM) from 1992 to 2018 was performed. The overall membership gender distribution was available from 2010 to 2018. Leadership positions included Committee Chair/Co-chair, Board of Governors, and Executive Committee. Three phenomena were investigated: "pipeline," by determining the change in women CMs compared to overall membership over time; "sticky floors," by comparing advancement beyond CM by gender; "glass-ceiling," by analyzing the promotion trajectory and time to leadership positions between genders. Statistical analysis comparing trends over time was performed using Kendall-tau. RESULTS: There were 1546 surgeons who served on at least one committee during the study period. Women represented 21% of CMs, 18% of chairs/co-chairs, 16% of board members and 14% of executives, with one woman President. The proportion of women CMs has significantly increased over time from 3% in 1992 to 27% in 2018 (p-trend < 0.001). A similar proportion of women and men advanced beyond CM (17% vs. 14%, p = 0.194), with no difference in time to advancement. From 2010 to 2018, the increase in the proportion of women CMs and board members outpaced that of overall women members (p < 0.05). Women executives surpassed overall women members in 2018 (29% vs. 19%). A similar proportion of men and women "skipped ranks" to reach the Board/Executive (37% vs. 25%, p = 0.307). CONCLUSION: The proportion of women in leadership positions within SAGES is higher than in the overall membership. There were no gender differences in the advancement of CMs to leadership positions. While these data are encouraging, SAGES should continue to foster the advancement of women surgeons.

Comparison of Dor and Nissen fundoplication after laparoscopic paraesophageal hernia repair.

BACKGROUND: Fundoplication is performed routinely during laparoscopic repairs of a paraesophageal hernia, but the degree of fundoplication remains controversial. The purpose of this study is to assess postoperative dysphagia and reflux after a Dor versus a Nissen fundoplication in patients undergoing laparoscopic repair of giant paraesophageal hernias. METHODS: We performed a retrospective cohort study of all patients undergoing laparoscopic repair of giant paraesophageal hernias with Nissen or Dor fundoplication between January 2012 and December 2017 at a high-volume center, excluding revisional and emergency cases. Primary outcomes were reflux and dysphagia at 1 and 6 months. Severe dysphagia was defined as intolerance to liquids. Balanced cohorts were created using coarsened exact matching. RESULTS: A total of 106 patients were included, and 87 were matched (Dor = 48, Nissen = 58). Baseline characteristics were well balanced between matched groups. Mean follow-up duration was 17.7 months (standard deviation 16.4). The incidence of severe dysphagia at 1 month was less in the Dor group (0 of 48 vs 8 of 58, P = .02) with similar reflux symptoms. There was no difference in severe dysphagia and reflux symptoms at 6 months and at the latest visit. CONCLUSION: Dor fundoplication is associated with less severe, early postoperative dysphagia. Future studies assessing the relative importance of dysphagia and reflux on quality of life should be conducted to tailor the operative technique and optimize patient satisfaction.