Unspoken Truths: Mental Health Among Academic Surgeons.

OBJECTIVE: To characterize the current state of mental health within the surgical workforce in the United States. BACKGROUND: Mental illness and suicide is a growing concern in the medical community; however, the current state is largely unknown. METHODS: Cross-sectional survey of the academic surgery community assessing mental health, medical error, and suicidal ideation. The odds of suicidal ideation adjusting for sex, prior mental health diagnosis, and validated scales screening for depression, anxiety, post-traumatic stress disorder (PTSD), and alcohol use disorder were assessed. RESULTS: Of 622 participating medical students, trainees, and surgeons (estimated response rate=11.4%-14.0%), 26.1% (141/539) reported a previous mental health diagnosis. In all, 15.9% (83/523) of respondents screened positive for current depression, 18.4% (98/533) for anxiety, 11.0% (56/510) for alcohol use disorder, and 17.3% (36/208) for PTSD. Medical error was associated with depression (30.7% vs. 13.3%, P <0.001), anxiety (31.6% vs. 16.2%, P =0.001), PTSD (12.8% vs. 5.6%, P =0.018), and hazardous alcohol consumption (18.7% vs. 9.7%, P =0.022). Overall, 13.2% (73/551) of respondents reported suicidal ideation in the past year and 9.6% (51/533) in the past 2 weeks. On adjusted analysis, a previous history of a mental health disorder (aOR: 1.97, 95% CI: 1.04-3.65, P =0.033) and screening positive for depression (aOR: 4.30, 95% CI: 2.21-8.29, P <0.001) or PTSD (aOR: 3.93, 95% CI: 1.61-9.44, P =0.002) were associated with increased odds of suicidal ideation over the past 12 months. CONCLUSIONS: Nearly 1 in 7 respondents reported suicidal ideation in the past year. Mental illness and suicidal ideation are significant problems among the surgical workforce in the United States.

Effective Mentoring Across Differences-Best Practices and Effective Models to Address the Needs of Underrepresented Trainees in Surgical Residency Programs.

BACKGROUND: Mentorship plays a critical role in the career development of surgical trainees and faculty. As the surgical workforce continues to diversify, mentoring trainees who differ) race, ethnicity, country of origin, socioeconomic status, educational background, religion, gender, sexual orientation or ability) can pose challenges to the experience for both mentor and mentee. OBJECTIVE: The aim of this manuscript is to introduce surgical educators to the systemic barriers faced by trainees and to models of effective mentorship. METHODS: At the 2022 APDS Meeting, a panel convened to highlight the current challenges of mentoring across differences and effective models for surgical educators. This paper highlights and expands the summary of this panel. RESULTS: Examples of novel mentoring models are described. CONCLUSIONS: Acknowledgment of barriers, Implementation of deliberate mentoring strategies, and collaboration with national surgical organizations and surgery departments and faculty may help to reduce physician attrition.

General Surgery Twitter during COVID-19: Tweets, Trends, and Implications for Recruitment Strategies.

BACKGROUND: The COVID-19 pandemic has disrupted traditional resident recruitment practices, requiring virtual interviews and new forms of outreach. Social media, such as Twitter, is one tool programs can use to connect with applicants. This study sought to assess changes in Twitter use during the COVID-19 pandemic among general surgery programs. METHODS: Twitter and residency program websites were queried for public Twitter accounts related to general surgery residency programs. Publicly available tweets for available accounts were reviewed for all posts for the period March 15, 2019-November 25, 2020. Thematic analysis of each tweet was performed, and engagement was determined by likes and retweets on each tweet. RESULTS: The number of programs with active Twitter accounts increased after the onset of COVID-19 pandemic, as did the number of tweets, likes-, and retweets-per-tweet. There was a significant increase in the number of tweets regarding resident promotion, program promotion, and virtual event promotion. Tweets received more likes-per-tweet if the subject was program promotion and resident promotion than tweets regarding virtual events. All results were statistically significant (P < .05). DISCUSSION: Twitter use and engagement with residency programs have increased significantly since pandemic onset. Engagement is highest for tweets regarding program and resident promotion as measured by likes-per-tweet and highest for program promotion and virtual events as measured by retweets-per-tweet. Given the nearly nationwide increase in Twitter engagement after pandemic onset, programs should consider the impact of Twitter as a means of communication with applicants and program branding.

Leadership Diversity in the Association of Program Directors in Surgery: A Report of Progress.

BACKGROUND: Across the last several years, numerous surgical departments and societies have focused on addressing the lack of diversity, equity, and inclusion (DEI) in the field. Since the Association of Program Directors in Surgery (APDS) Diversity and Inclusion Taskforce was created in 2017 (and solidified as a formal committee in 2018, herein referred to as the APDS-DIC), it has sought to address gaps in diversity at various phases of training and development from medical student to surgical leader. OBJECTIVE: In follow-up to a 2018 study that benchmarked leadership demographics of the APDS, this study analyzed how the APDS' efforts have aligned with recommended DEI strategies and whether this produced demographic changes in organizational leadership. METHODS: Fifteen years (2008-2022) of publicly available APDS annual meeting program data and APDS membership lists were analyzed. Leadership positions in the organization were examined by officer, program/vice chair, executive committee, and board of directors. A 2-tailed T-test compared differences in the average proportion of leaders from specific demographic groups before and after the APDS-DIC inception (2008-2016 vs. 2017-2022). RESULTS: APDS has 724 unique faculty and 140 resident members. The majority of both groups identified as White (68% of faculty and 58% of residents). Over 15 years, there have been 307 available leadership positions held by 67 individuals. All presidents and president-elect positions have been held by White surgeons; nearly 80% have been men. The average proportion of female leaders and the average proportion of racial/ethnic minority leaders were both significantly higher after implementation of the APDS-DIC in 2017 (p=0.0009 for gender and p=0.036 for racial/ethnic minorities). CONCLUSIONS: The APDS' commitment to DEI efforts and establishment of the APDS-DIC in 2017 was associated with a significant increase in women and non-White minorities in organizational leadership positions. The specific role of the APDS-DIC in propelling surgeons from underrepresented groups into leadership and promoting key DEI efforts is broadly applicable to other surgical organizations.

Citizenship and Social Responsibility in Surgery: A Review.

Importance: Social determinants of health have been shown to be key drivers of disparities in access to surgical care and surgical outcomes. Though the concept of social responsibility has received growing attention in the medical field, little has been published contextualizing social responsibility in surgery. In this narrative review, we define social responsibility as it relates to surgery, explore the duty of surgeons to society, and provide examples of social factors associated with adverse surgical outcomes and how they can be mitigated. Observations: The concept of social responsibility in surgery has deep roots in medical codes of ethics and evolved alongside changing views on human rights and the role of social factors in disease. The ethical duty of surgeons to society is based on the ethical principles of benevolence and justice and is grounded within the framework of the social contract. Surgeons have a responsibility to understand how factors such as patient demographics, the social environment, clinician awareness, and the health care system are associated with inequitable patient outcomes. Through education, we can empower surgeons to advocate for their patients, address the causes and consequences of surgical disparities, and incorporate social responsibility into their daily practice. Conclusions and Relevance: One of the greatest challenges in the field of surgery is ensuring that surgical care is provided in an equitable and sustainable way. Surgeons have a duty to understand the factors that lead to health care disparities and use their knowledge, skills, and privileged position to address these issues at the individual and societal level.

A Novel Mock Oral Curriculum for Senior Surgery Residents: Results of a Pilot Study.

INTRODUCTION: The oral general surgery certifying examination (CE) is required for board certification. A curriculum was designed to improve CE passage rates at an academic residency program. Limited literature exists that evaluates a long-term mock oral curriculum for senior residents. This study aims to evaluate the impact of this curriculum on essential elements for clinical practice and CE preparedness. METHODS: The curriculum consisted of weekly meetings with postgraduate year four and postgraduate year five residents (n = 10). Two residents were selected for a video-recorded board-style mock examination with a faculty examiner and peer audience. Each attendee completed a standard evaluation form that assessed score, anxiety, confidence, and medical knowledge. Blood pressure, pulse, and unused time were assessed. A postcurriculum survey was conducted. RESULTS: Medical knowledge had the greatest correlation with overall scores (R2 = 0.733). Positive correlations were seen between confidence and case number for faculty, self, and peer scores (R2 = 0.671, R2 = 0.566, and R2 = 0.729, respectively). There was a positive correlation between confidence and medical knowledge (R2 = 0.575). There was a significant difference between the overall score of nontachycardic versus tachycardic residents (P = 0.00994). CONCLUSIONS: Residents demonstrated increasing confidence as they progressed through the curriculum by self-reported and objective measures. Residents demonstrated improvements in overall scores. Future directions will examine results of the 2-y curriculum experience and CE passage rates to verify that a standardized, structured, weekly, longitudinal curriculum is beneficial for CE preparedness and clinical practice.

Patient and Physician Attitudes Toward Telemedicine in Cancer Clinics Following the COVID-19 Pandemic.

PURPOSE: COVID-19 has infected more than 94 million people worldwide and caused more than 2 million deaths. Patients with cancer are at significantly increased risk compared with the general population. Telemedicine represents a common strategy to prevent viral spread. We sought to evaluate patient with cancer and physician perceptions of telemedicine during the COVID-19 pandemic. METHODS: A 16-question survey was e-mailed to 1,843 active e-mails of patients presenting to one of the six cancer clinics at a comprehensive cancer care center from January 1, 2020, to June 1, 2020. A six-question survey was e-mailed to attending physicians of those clinics. Specialties included Medical Oncology, Hematology-Oncology, Surgical Oncology, Urological Oncology, and Gynecologic Oncology. RESULTS: Three hundred seventy-four patients (20.3%) and 14 physicians (66.7%) responded. Most (68.2%) currently prefer in-person visits, and 80.4% prefer in-person visits following pandemic resolution. More than half (52.2%) of patients preferring virtual visits do so because of convenience. Most (63.1%) patients with cancer are comfortable with a complete physical examination. Surgical patients are more likely to prefer a complete examination (P = .0476). Physicians prefer in-person visits (64.2%) and believe that virtual visits maybe or probably do not provide comparable care (64.2%). 71.4% believe that virtual visits help prevent the spread of infectious disease. CONCLUSION: Given preferences for in-person visits, cancer care teams should be prepared to continue providing in-person visits for many of their patients. The discrepancy between patient and provider concern for spread of infectious disease represents an area where patients may benefit from increased education. Providers should feel comfortable performing physical examinations at their own discretion.

Barriers to Accurate Fluid Measurement in Perioperative Patients: A Mixed Methods Approach.

BACKGROUND: Surgeons depend on fluid intake and output (I/O) measurements for assessment of resuscitation and fluid balance during the perioperative period. Frequently, these measurements are taken by Registered Nurses (RNs) and/or Patient Care Technicians (PCTs). There is variability in the accuracy and consistency of these measurements across nursing units. The goal of this study is to establish what barriers exist in obtaining accurate fluid measurements and potential solutions. MATERIALS AND METHODS: A mixed-method, sequential study design was utilized. First, a survey was conducted at a tertiary care institution of 8 nonintensive care nursing units assessing the perceptions of RNs (n = 85) and PCTs (n = 38) regarding fluid intake and output measurements for surgical patients. Four focus groups were then conducted to expand upon the results of the survey. Fourteen participants (10 RNs and 4 PCTs) were interviewed, and transcripts were analyzed by three reviewers. Qualitative data were manually coded by reviewers using a hierarchical methodology. RESULTS: Survey response rate was 40.6%. The strongest barriers in the survey were patient load and staff time limitations. About half (49%) of the respondents acknowledged that fluid measurements were inaccurate half of the time. PCTs spend more time collecting and charting I/Os and have higher patient loads (P < 0.001) than RNs. PCTs noted more difficulty with complex patients (P = 0.017) and devices for outputs (P = 0.004). PCT's (94%) handwrite data prior to electronic entry. One-third of nurses reported direct electronic entry (P < 0.001). Overall, 71% would prefer to chart in patient's rooms. Most (80%) of respondents received <5 h of fluids-related training at the time they were hired. Cronbach's alpha for three focus group reviewers was 0.84 (95% CI 0.693-0.923). Themes included understaffing, lack of training, a high percentage of traveling nurses, and poor communication regarding new orders. Recommended solutions to improve I/Os included in-room kiosks for electronic entry and relief of staffing burdens. CONCLUSIONS: Fluid I/O measurement accuracy and efficiency may be improved by increased staffing, educational programs, and computer access, streamlining of order sets, simplicity of EMR data entry, and a standardized process for measuring, recording, and charting I/Os.

Diversity, Equity and Inclusion in Medicine: Why It Matters and How do We Achieve It?

Diversifying the medical work force is critical to reducing health care disparity and improving patient outcomes. This manuscript offers a comprehensive review of best practices to improve both the recruitment and the retention of underrepresented minorities in training programs and beyond.

Do General Surgery Residency Program Websites Feature Diversity?

OBJECTIVE: This study assesses ways in which General Surgery residency program websites demonstrate diversity. DESIGN: Literature review and diversity expert opinion informed selection of diversity elements. We limited our evaluation to residency program-specific webpages. We identified 8 program website elements that demonstrate programmatic commitment to diversity: (1) standard nondiscrimination statement; (2) program-specific diversity and inclusion message; (3) community demographics; (4) personalized biographies of faculty, (5) personalized biographies of residents; (6) individual photographs of faculty; (7) individual photographs of residents; and (8) list of additional resources available for trainees. We evaluated the impact of program type (university, independent, or military); city population; region; program director gender and ethnicity; and program size on incorporation of these eight elements. We dichotomized programs that had ≥4 of these elements on their website and determined association with the above factors using chi-square or Fisher's exact test. SETTING: Website review July to December 2019. PARTICIPANTS: All nonmilitary-based general surgery residency program members of the Association of Program Directors in Surgery (APDS) (n = 242/251). RESULTS: General Surgery residency program websites included a mean of 2.7 ± 1.5 elements that showcase diversity. Most program websites (n = 215, 89%) featured ≤4 elements (range 1-4), while 15 (6.2%) had none. When stratified by programs having 4 or more elements on their website, university-based program (p < 0.001) was the only factor associated. Resident photos (n = 147, 61%), resources available to trainees (n = 146, 60%), faculty photos (n = 139, 57%), and community demographics (n = 93, 38%) were the most common of the 8 website elements. CONCLUSIONS: Residency program websites are vital to recruiting applicants. Featuring specific elements on the General Surgery residency website that display a program's commitment to diversity and inclusion may be important in attracting a diverse candidate pool. This research highlights opportunities programs may use to demonstrate more effectively a residency program's commitment to diversity and inclusion.

Urgent Surgery for Gastric Adenocarcinoma: A Study of the National Cancer Database.

BACKGROUND: Gastric adenocarcinoma is a leading cause of cancer death worldwide and, in the United States, can present emergently with upper GI hemorrhage, obstruction, or perforation. No large studies have examined how urgent surgery affects patient outcomes. This study examines the outcomes of urgent versus elective surgery for gastric cancer. MATERIALS AND METHODS: Patients with gastric adenocarcinoma from the National Cancer Database from 2004 to 2015 were examined retrospectively. Patients with metastatic disease or incomplete data were excluded. Urgent surgery was defined as definitive surgery within 3 d of diagnosis. Univariate and multivariate analysis of patient factors, surgical outcomes, and oncologic data was performed. P-values <0.05 were statistically significant. RESULTS: Of 26,116 total patients, 2964 had urgent surgery and 23,468 had elective surgery. Urgent surgery patients were significantly older, were female, were nonwhite, had higher pathologic stage, and were treated at a low-volume center. Urgent surgery was associated with decreased quality lymph node harvest (odds ratio [OR] 0.68 95% confidence interval {CI} [0.62, 0.74]), increased positive surgical margin (OR 1.48, 95% CI [1.32, 1.65]), increased 30-d mortality (OR 1.38, 95% CI [1.16, 1.65]), increased 90-d mortality (OR 1.30, 95% CI [1.14, 1.49]), and decreased overall survival (hazard ratio 1.21, 95% CI [1.15, 1.27]). CONCLUSIONS: Urgent surgery for gastric cancer is associated with significantly worse outcomes than elective surgery. Stable patients requiring urgent surgical resection for gastric cancer may benefit from referral to a high-volume center for resection by an experienced surgeon. Patients undergoing urgent resection for gastric cancer should be referred to surgical and medical oncologists to ensure they receive appropriate adjuvant therapy and surveillance.

MAGIC versus MacDonald treatment regimens for gastric cancer: Trends and predictors of multimodal therapy for gastric cancer using the National Cancer Database.

BACKGROUND: Multimodal therapy is beneficial in gastric cancer, however this practice is not universal. This study examines trends, identifies associative factors, and examines overall survival (OS) benefit from multimodal therapy in gastric cancer. METHODS: Gastric cancer patients staged IB-III from 2005 to 2014, identified using the National Cancer Database, were categorized by treatment: surgery alone, perioperative chemotherapy, and adjuvant chemoradiation. Groups were analyzed to identify associative factors of perioperative therapy. RESULTS: We examined 9243 patients, with the majority receiving multimodal therapy (57%). The proportion of those receiving perioperative chemotherapy rose dramatically from 7.5% in 2006 to 46% in 2013. Academic center treatment was strongly associated with perioperative over adjuvant therapy (p < 0.0001). An OS advantage was clearly seen in those receiving multimodal therapy versus surgery alone (p < 0.0001), with no difference between perioperative and adjuvant therapies. CONCLUSIONS: Treatment of gastric cancer with multimodal therapy has risen significantly since 2005, largely due to increasing use of perioperative chemotherapy. As perioperative therapy becomes more prevalent, more patients will have the opportunity for the improved survival benefit of multimodal therapy.

Diversity in the Last Decade of the Association of Program Directors in Surgery: A Descriptive Analysis of Leadership and Future Directions.

OBJECTIVE: The Association of Program Directors in Surgery Diversity and Inclusion Taskforce (APDS-DIT) was created in 2017 after the Executive Committee recognized low diversity in its membership. The DIT was charged to address gaps in diversity and inclusion at various phases of training and development from medical student to surgical leader. The aim of this study was to examine APDS demographics and determine the status of inclusion of women, racial and ethnic minorities, and nonuniversity surgeons. DESIGN: Eleven years (2008-2018) of APDS annual-meeting programs, web directory, 2018-membership lists, and 2017-AAMC data were analyzed. Leadership positions were examined by officer (program chair/vice chair, executive committee, and board of directors. Internet searches identified gender, race, and institutional affiliation. Representative members to other organizations, resident liaisons, and historian members were excluded. APDS "Member," "Associate," and "Resident" lists and AAMC data were divided by gender. RESULTS: Fifty-one individuals fulfilled 223 leadership positions over 11 years; 13 (25%) were women and 5 (10%) were non-Caucasian. Since 2013, the percentage of nonuniversity surgeons in APDS leadership has declined while, over the last 2 years, the percentage of women and ethnic/racial minority has increased. In 2018, the percentage of women in leadership (38%) was higher than the percentage of women in membership (combined total of program directors and associate program directors [26%]) and nonuniversity-affiliated surgeons comprised 35% of the APDS membership but only 14% of leadership roles. CONCLUSIONS: Over the last 11 years, representation of women, non-Caucasians, and nonuniversity surgeons has been at or less than 1/3 of their counterparts. As an organization that is tasked with creating future generations of the surgical workforce, it is imperative to recognize an under-representation of those members with diverse backgrounds that would add to the creative growth of the organization. The creation of the APDS-DIT emphasizes the organization's commitment to diversity and inclusion and an effort to create a pipeline of diverse leaders in the APDS and surgical training in general.

Multi-institutional Surgical Education Interventions: A Scoping Review.

OBJECTIVE: The aim of the study was to identify and evaluate scholarship in multi-institutional interventional surgical education trials. SUMMARY BACKGROUND DATA: Most research on interventions in surgical education occurs at individual institutions. These studies typically involve a small number of learners in a unique environment, thereby limiting their generalizability. The status of multi-institutional studies in surgical education remains unknown. METHODS: We searched the Pubmed, ERIC, PsycINFO, SCOPUS, and CINAHL databases for all English language articles published from January 1, 2000 to December 31, 2015 using the keywords "medical education," "surgical education," "multi-institutional," "multi-center," and related terms. Articles published in an English language peer-reviewed journal that described an educational intervention conducted at more than one institution and involving surgeons were included. RESULTS: Of 3511 identified articles, 53 met criteria for full-text review and inclusion in this review. The median number of institutional sites was 4, with a range of 2 to 54. The 2 most common areas of focus were technical skills (43% of studies) and clinical knowledge (32% of studies). These were also the 2 most commonly measured outcomes (technical skills 32% of studies, clinical knowledge 21% of studies). Thirteen percentage of studies measured only learner attitudes and perceptions rather than learning outcomes. CONCLUSIONS: Multi-institutional surgical education studies do not uniformly incorporate characteristics of high quality research, particularly related to study design, measurable outcomes, and assessment tools used. Coordinated support, including grant funding, that addresses the challenging nature of multi-institutional surgical education research may improve the quality of these studies.

Lymph Node Harvest as a Measure of Quality and Effect on Overall Survival in Esophageal Cancer: A National Cancer Database Assessment.

Surgical therapy for esophageal cancer is the cornerstone of treatment, and the highest quality operation should lead to the highest cure rate. Evaluated lymph node (ELN) count is one quality measure that has been championed. The objective of this study was to explore ELN in esophagectomy, examine predictors of harvesting ≥12 nodes, and determine whether higher ELN improves overall survival (OS). ELN was examined in patients with resected esophageal cancer using the National Cancer Database from 2004 to 2013. In this study, 41,746 patients met the inclusion criteria. Fifty-two per cent of patients had 12 or more nodes harvested. Academic programs were most likely to harvest ≥12 nodes (58% of cases) compared with other programs (43-56% of cases). Seventy per cent of cases with ≥12 nodes harvested were performed at high-volume centers. Preoperative radiation or preoperative chemoradiation led to lower ELN (46% and 48%) versus preoperative chemotherapy alone (66%). Multivariate analysis showed that patients who had ≥12 nodes removed had better OS (Hazard Ratio 0.843 [95 confidence interval 0.820-0.867]). In addition, care at a high-volume facility, care at an academic facility, private insurance, and income ≥$63,000 were all associated with improved OS. Higher ELN count is associated with OS in patients with esophageal cancer. Patients who receive care at high-volume centers and academic centers are more likely to undergo more extensive lymphadenectomy. All centers should strive to examine at least 12 nodes to provide a quality esophagectomy.

Neoadjuvant versus Adjuvant Chemotherapy for Resectable Pancreatic Adenocarcinoma: A National Cancer Database Analysis.

There is controversy regarding the role of neoadjuvant versus adjuvant chemotherapy for pancreatic cancer (PAC). Neoadjuvant therapy has been touted as a method to improve survival in PAC patients. This study's objective is to investigate predictors and potential benefits of neoadjuvant therapy in resectable PAC patients. The National Cancer Data Base was used to retrospectively analyze stage I and II surgically resected PAC patients receiving adjuvant or neoadjuvant therapy from 2004 to 2012. A total of 12,983 patients were identified. A significant increase in the rate of neoadjuvant therapy was observed over time with 5 per cent receiving neoadjuvant therapy in 2004 versus 17 per cent in 2012 (P < 0.0001). Multivariate analysis showed that patients were more likely to receive neoadjuvant therapy if they were treated at an academic facility. Private insurance was associated with higher odds of neoadjuvant chemotherapy (P < 0.0001). Pathological outcomes were improved in neoadjuvant patients compared with adjuvant patients on multivariate analysis with neoadjuvant patients having higher rates of negative surgical margins (OR: 1.273, 95% Confidence interval: 1.099-1.474) and negative lymph nodes (OR: 2.852, 95% Confidence interval: 2.547-3.194). Pathological outcomes are improved after neoadjuvant therapy compared with adjuvant therapy, with more patients achieving negative margins and negative lymph nodes. Prospective studies are needed to compare these two treatment modalities in a head to head comparison.

Esophagectomy: Comparison of Short-Term Outcomes between Single-versus Two-Team Approach.

Literature about combining expertise of two specialties in esophageal cancer surgery is limited. We present the experience at a single institute comparing single-team (ST) versus two-team (TT) approach combining thoracic and abdominal surgeons. This is a retrospective study from a single tertiary care center. Data were collected from electronic medical records. Patients undergoing esophagectomy for esophageal cancer from November 2006 until August 2014 were included. The primary outcome measured was 30-day postoperative morbidity, secondary outcomes measured were operative time, intraoperative blood loss, and 30-day mortality. Results are reported as mean with an interquartile range. Forty-nine patients underwent esophagectomy by an ST and 51 patients by TT. Patient demographics, tumor characteristics, stage, pathology, and use of neoadjuvant therapy were comparable between groups. Charlson comorbidity index was significantly higher in TT group [3 (2, 4) vs 2 (2, 3), P = 0.02]. The TT group had a significantly shorter operative time compared to the ST group [304 (252,376) minutes vs 438 (375, 494] minutes, P < 0.0001). Intraoperative blood loss was 300 (200, 550) mL for the TT group and 250 (200,400) mL for the ST group (P = 0.29). There was no difference in 30-day postoperative morbidity (68.6% for TT, 59.2% for ST, P = 0.32) and mortality (2% each, P = 1) between the two groups. In conclusion, the operative time by the TT approach was significantly shorter than the ST approach with comparable postoperative morbidity and mortality. Long-term follow-up is needed to study this approach's effect on long-term survival.