Subtotal vs total cholecystectomy for difficult gallbladders: A systematic review and meta-analysis.

INTRODUCTION: With severely inflamed gallbladders, laparoscopic cholecystectomy can be difficult and may require procedures like subtotal cholecystectomy (SC). Few studies exist comparing SC and total cholecystectomy (TC) in the setting of severe biliary inflammation. This meta-analysis aims to compare SC and TC for difficult gallbladders. METHODS: Medline-OVID, Embase-OVID, and Cinahl were searched including only studies comparing SC to TC for difficult gallbladders. Primary outcome was CBD injury. Secondary outcomes included bile leak, duodenal injury, retained stone, bleeding, intraabdominal collection, wound infection, reoperation, and mortality. RESULTS: Ten studies were included. Compared to TC, SC significantly lowered the risk for CBD injury (0 â€‹% vs. 1.6 â€‹%, RR 0.30, 95%CI 0.10-0.87) but increased risk of bile leaks (RR 3.5, 95%CI 1.79-6.84), postoperative ERCP (RR 2.86, 95%CI 1.53-5.35), intraabdominal collections (RR 2.55, 95%CI 1.32-4.93), and reoperation (RR 2.92, 95%CI 1.14-7.47). CONCLUSION: SC is a reasonable alternative to difficult gallbladders that may decrease the risk of CBD injuries. Knowing both approaches is crucial to manage the difficult gallbladder while minimizing harm. Further studies are needed to understand the value of SC for difficult cholecystectomy.

Measuring the Impact of a Formalized Surgical Patient Signout System.

OBJECTIVE: Routine patient signout within medical teams is an integral component of patient care. Standardized signout systems have shown lowered risks of harm and adverse outcomes to patients, however, many of these systems are difficult to utilize with surgical patients. The purpose of this study was to determine if a standardized surgical signout model would improve resident satisfaction of the signout process and improve resident preparedness for cross-covered services. DESIGN: A 16-question survey was administered to the surgical residents at a single general surgery residency program. A standardized signout using the mnemonic "CUTS" (Core problem, Updates, Things-to-do, Setbacks) was then implemented in the program. Residents retook the survey at 1, 3, and 6-month intervals to compare resident satisfaction on signout before and after the standardized signout implementation. The descriptive statistics of the survey were analyzed for trends over time, trends by resident training year, and for inferential statistics utilizing subscales. RESULTS: The descriptive statistics showed that there was an overall trend towards greater resident satisfaction with signout over time with satisfaction increasing from 41.1% to 80% in the general resident cohort. While there were no statistically significant differences, subscale analysis demonstrated greatest trends for improved satisfaction with the CUTS signout model for the PGY1 and PGY5 classes. There was additionally an increased resident preparedness for overnight events and calls, with a 27% increase in perceived preparedness "75% of the time" and a 5.5% increase in perceived preparedness "Always". There was no difference in time spent on signout after the implementation of the model. CONCLUSIONS: The surgical standardized signout model, CUTS, demonstrated that residents within a single program were more satisfied with signouts, had improved patient understanding and knowledge, and felt increased preparedness for overnight events on cross-covered patients. Further research is needed to determine the impact of the CUTS signout system on patient outcomes.

Implementation of a Business of Healthcare Curriculum for General Surgery Residents.

OBJECTIVE: To better prepare general surgery residents for handling the business aspects of healthcare, this project evaluation reports on the implementation of a business of healthcare curriculum (BHC) in a general surgery residency program. We evaluated (pre and post curriculum) self-perceived knowledge and attitudes toward common business topics. DESIGN: General surgery residents were administered a 13-item survey (7 Likert-type and 3 open-ended items assessing self-perceived knowledge and attitudes toward BHC, and 3 demographic questions) prior to the start of the curriculum. The curriculum was comprised of four core sessions, which included didactic lectures and group projects, including the creation of a business plan. At the conclusion of the curriculum, a post-test with the same items was administered. A total of 21 residents completed both the pre and post-tests. SETTING: The BHC was a mandatory part of the general surgery residency program and was conducted in Honolulu, Hawaii (University of Hawaii at Manoa). PARTICIPANTS: All general surgery residents, PGY-1 to PGY-5, were required to participate in the curriculum. RESULTS: Statistically significant increases in resident knowledge were found overall and specifically for healthcare reform legislation, differences between practice settings, financial matters, contracting and coding and billing for services. Additionally, responses to open-ended questions showed that residents had a positive attitude toward the curriculum and found it useful. CONCLUSIONS: General surgery residency programs can successfully create an impactful business of healthcare curriculum with minimal cost if volunteers and existing resources are utilized.

Characteristics Associated With Outstanding General Surgery Residency Graduate Performance, as Rated by Surgical Educators.

Importance: Characteristics of outstanding graduating surgical residents are currently undefined. Identifying these qualities may be important in guiding resident selection and resident education. Objective: To determine characteristics that are most strongly associated with being rated as an outstanding graduating surgical resident. Design, Setting, and Participants: The multi-institutional study had 3 phases. First, an expert panel developed a list of characteristics embodied by top graduating surgical residents. Second, groups of faculty from 14 US general-surgery residency programs ranked 2017 through 2020 graduates into quartiles of overall performance. Third, faculty evaluated their graduates on each characteristic using a 5-point Likert scale. Data were analyzed using Spearman rank-order correlation to identify which individual characteristics were associated with overall graduate performance. A least absolute shrinkage and selection operator (LASSO) ordinal regression was performed to select a parsimonious model to predict the outcome of overall performance rating from individual characteristic scores. Main Outcome and Measures: Surgical educators' rankings of general surgery residency graduates' overall performance. Results: Fifty faculty from 14 US residency programs with a median of 13 (range, 5-30) years of surgical education experience evaluated 297 general surgery residency graduates. Surgical educators identified 21 characteristics that they believed outstanding graduating surgical residents possessed. Two hundred ninety-seven surgical residency graduates were evaluated. Higher scores in every characteristic correlated with better overall performance. Characteristics most strongly associated with higher overall performance scores were surgical judgment (r = 0.728; P < .001), leadership (r = 0.726; P < .001), postoperative clinical skills (r = 0.715; P < .001), and preoperative clinical skills (r = 0.707; P < .001). The remainder of the characteristics were moderately associated with overall performance. The LASSO regression model identified 3 characteristics from which overall resident performance could be accurately predicted without measuring other qualities: surgical judgment (odds ratio [OR] per 1 level of 5-level Likert scale OR, 1.27; 95% CI, 1.03-1.51), leadership (OR, 1.27; 95% CI, 1.06-1.48), and medical knowledge (OR, 1.16; 95% CI, 1.01-1.33). Conclusions and Relevance: All individual characteristics identified by surgical educators as being qualities of outstanding graduating surgical residents were positively associated with overall graduate performance. Surgical judgment and leadership skills had the strongest individual associations. Assessment of only 3 qualities (surgical judgment, leadership, and medical knowledge) were required to predict overall resident performance ratings. These findings highlight the importance of developing specific surgical judgment and leadership skills curricula and assessments during surgical residency.

Defining benchmarks for fellowship training in foregut surgery: a 10-year review of fellowship council index cases.

INTRODUCTION: Surgical treatment of foregut disease is a complex field that demands advanced expertise to ensure favorable outcomes for patients. To address the growing need for foregut surgeons, leaders within several national societies have become interested in developing a foregut fellowship. The aim of this study was to develop data-driven benchmarks that will aid in defining appropriate accreditation criteria for these fellowships. METHODS: We obtained case log data for Fellowship Council fellows trained from 2009-2019. We identified 78 complex foregut (non-bariatric) case codes and divided them into 5 index case categories including (1) hiatal/paraoesophageal hernia repair, (2) fundoplication, (3) esophageal myotomy, (4) major organ resection, and (5) minor organ resection. Median volumes in each index category were compared over time using Kruskall-Wallis tests. The share of cases done using open, laparoscopic, or robotic approaches were analyzed using linear regression analysis. RESULTS: For the 10 years analyzed, 1362 fellows logged 82,889 operations and 111,799 endoscopies. Median foregut cases per fellow grew significantly from 42 (IQR = 24-74) cases in 2010 to 69 (IQR = 33-106) cases in 2019. Median endoscopy volumes also grew significantly from 42 (IQR = 7-88) in 2010 to 69 (IQR 32-123) in 2019.The volume of hiatal/paraoesophageal hernia repairs increased significantly over time while volumes in the remaining 4 index categories remained stable. The share of robotic cases exhibited near perfect linear growth from 2.2% of all foregut cases in 2010 to 14.4% in 2019 (R = 0.99, p < 0.0001). Open cases exhibited linear decay from 7.2% of cases in 2010 to 4.7% of cases in 2019 (R = 0.92, p = 0.0001). Laparoscopic/thoracoscopic cases also exhibited linear decay from 90.6% of cases in 2010 to 80.9% of cases in 2019 (R = 0.98, p < 0.00001). CONCLUSIONS: FC fellows are exposed to robust volumes of foregut cases. This rich data set provides an evidence-based guide for establishing criteria for potential foregut fellowships.

Predictors and Consequences of Unplanned Conversion to Open During Robotic Colectomy: An ACS-NSQIP Database Analysis.

Robotic-assisted surgery has become a desired modality for performing colectomy; however, unplanned conversion to an open procedure may be associated with worse outcomes. The purpose of this study is to examine predictors and consequences of unplanned conversion to open in a large, high fidelity data set. A retrospective analysis of 11 061 robotic colectomies was conducted using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) 2012-2017 database. Predictors of conversion and the effect of conversion on outcomes were analyzed by multivariate logistic regression resulting in risk-adjusted odds ratios of conversion and morbidity/mortality. Overall, 10 372 (93.8%) patients underwent successful robotic colectomy, and 689 (6.2%) had an unplanned conversion. Predictors of conversion included age ≥ 65 years, male gender, obesity, functional status not independent, American Society of Anesthesia (ASA) classification IV-V, non-oncologic indication, emergency case, smoking, recent weight loss, bleeding disorder, and preoperative organ space infection. Conversion is an independent risk factor for mortality, overall morbidity, cardiac morbidity, pulmonary morbidity, renal morbidity, venous thromboembolism morbidity, wound morbidity, sepsis, bleeding, readmission, return to the operating room, and extended length of stay (LOS). Unplanned conversion to open during robotic colectomy is an independent predictor of morbidity and mortality.

The Effect of Energy Devices, Nerve Monitors, and Drains on Thyroidectomy Outcomes: An American College of Surgeons National Surgical Quality Improvement Project Database Analysis.

The effect of energy devices, nerve monitors, and drains on thyroidectomy outcomes has been examined for each tool independently. Current literature supports the routine use of energy devices and nerve monitors and does not support the routine use of drains. The effect of these operative tools is interrelated and should be examined concurrently. The aim of this study was to describe the risk-adjusted effect of each of these tools on thyroidectomy outcomes. A retrospective analysis of 17 985 open thyroidectomy procedures was conducted using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) 2016-2018 thyroidectomy targeted procedure database. All open thyroidectomies were included. The risk-adjusted effect of energy devices, nerve monitors, and drains on 30-day outcomes was calculated by multiple logistic regression. Energy devices were associated with a decreased risk of hematoma and decreased extended length of stay without increased risk of hypocalcemia or recurrent laryngeal nerve injury. Nerve monitors were associated with a decreased risk of overall morbidity, decreased recurrent laryngeal nerve injury, and decreased extended length of stay without an increased risk of adverse outcomes. Drains were associated with an increased risk of bleeding, reoperation, and extended length of stay without decreasing hematoma. Our results support the routine use of energy devices and nerve monitors for thyroidectomy and do not support the routine use of drains for thyroidectomy.

Non-technical skill assessments across levels of US surgical training.

BACKGROUND: To ensure safe patient care, regulatory bodies worldwide have incorporated non-technical skills proficiency in core competencies for graduation from surgical residency. We describe normative data on non-technical skill ratings of surgical residents across training levels using the US-adapted Non-Technical Skills for Surgeons (NOTSS-US) assessment tool. METHODS: We undertook an exploratory, prospective cohort study of 32 residents-interns (postgraduate year 1), junior residents (postgraduate years 2-3), and senior residents (postgraduate years 4-5)-across 3 US academic surgery residency programs. Faculty went through online training to rate residents, directly observed residents while operating together, then submitted NOTSS-US ratings on specific resident's intraoperative performance. Mean NOTSS-US ratings (total range 4-20, sum of category scores; situation awareness, decision-making, communication/teamwork, leadership each ranged 1-5, with 1=poor, 3=average, 5=excellent) were stratified by residents' training level and adjusted for resident-, rater-, and case-level variables, using mixed-effects linear regression. RESULTS: For 80 operations, the overall mean total NOTSS-US rating was 12.9 (standard deviation, 3.5). The adjusted mean total NOTSS-US rating was 16.0 for senior residents, 11.6 for junior residents, and 9.5 for interns. Adjusted differences for total NOTSS-US ratings were statistically significant across the following training levels: senior residents to interns (6.5; 95% confidence interval, 4.3-8.7; P < .001), senior to junior residents (4.4; 95% confidence interval, 2.5-6.2; P < .001), and junior residents to interns (2.1; 95% confidence interval, 0.3-3.9; P = .017). Differences in adjusted NOTSS-US ratings across residents' training levels persisted for individual NOTSS-US behavior categories. CONCLUSION: These data and online training materials can support US residency programs in determining competency-based performance milestones to develop surgical trainees' non-technical skills.

A multi-institutional study assessing general surgery faculty teaching evaluations.

BACKGROUND: Resident evaluation of faculty teaching is an important metric in general surgery training, however considerable variability in faculty teaching evaluation (FE) instruments exists. STUDY DESIGN: Twenty-two general surgery programs provided their FE and program demographics. Three clinical education experts performed blinded assessment of FEs, assessing adherence 2018 ACGME common program standards and if the FE was meaningful. RESULTS: Number of questions per FE ranged from 1 to 29. The expert assessments demonstrated that no evaluation addressed all 5 ACGME standards. There were significant differences in the FEs effectiveness of assessing the 5 ACGME standards (p < 0.001), with teaching abilities and professionalism rated the highest and scholarly activities the lowest. CONCLUSION: There was wide variation between programs regarding FEs development and adhered to ACGME standards. Faculty evaluation tools consistently built around all suggested ACGME standards may allow for a more accurate and useful assessment of faculty teaching abilities to target professional development.

Predictors and Consequences of Hematoma After Thyroidectomy: An American College of Surgeons National Surgical Quality Improvement Program Database Analysis.

BACKGROUND: Hematoma after thyroid surgery is a serious complication. The purpose of this study was to determine the predictors and consequences of hematoma after thyroid surgery. MATERIALS AND METHODS: A retrospective analysis of 11,552 open thyroidectomies was conducted using the American College of Surgeons National Surgical Quality Improvement Program 2016-2017 main and thyroidectomy-targeted procedure databases. Predictors of hematoma and the effect of hematoma on outcomes were analyzed by multivariate logistic regression, resulting in risk-adjusted odds ratios of hematoma and morbidity/mortality, respectively. Statistical analysis was performed using R version 3.5.1. RESULTS: We found that male gender (odds ratio 1.71, 95% confidence interval 1.25-2.32; P value 0.0007), Black race (1.89, 1.27-2.77; 0.0014), other race (1.76, 1.23-2.50; 0.0017), hypertension (1.68, 1.20-2.35; 0.0026), diabetes (1.45, 1.00-2.06; 0.0460), and bleeding disorders (3.63, 1.61-7.28; 0.0007) were independent risk factors for postoperative hematoma. The use of an energy device for hemostasis (0.63, 0.46-0.87; 0.0041) was independently associated with decreased hematoma rate. Postoperative hematoma was an independent risk factor for overall morbidity (3.04, 2.21-4.15; <0.0001), hypocalcemia (1.73, 1.08-2.66, 0.0162), recurrent laryngeal nerve injury (2.42, 1.57-3.60, <0.0001), pulmonary morbidity (18.91, 10.13-34.16, <0.0001), wound morbidity (10.61, 5.54-19.02, <0.0001), readmission (5.23, 3.34-7.92, <0.0001), return to operating room (90.73, 62.62-131.97; <0.0001), and length of stay greater than the median (5.10, 3.62-7.15, <0.0001). CONCLUSIONS: Identified by this study are the predictors of postthyroidectomy hematoma and the consequences thereof. Notably, the use of energy devices for hemostasis was shown to be protective of postoperative hematoma. The results of this study may guide pre- and intra-operative decision-making for thyroidectomy to reduce rates of postoperative hematoma.

Predictors and consequences of recurrent laryngeal nerve injury during open thyroidectomy: An American College of Surgeons National Surgical Quality Improvement Project database analysis.

BACKGROUND: Recurrent laryngeal nerve (RLN) injury is a serious complication of thyroidectomy. The purpose of this study is to determine the predictors and consequences of RLN injury during thyroidectomy. METHODS: A retrospective analysis was conducted using the ACS-NSQIP 2016-2017 main and thyroidectomy targeted procedure databases. Data was analyzed by multivariate logistic regression resulting in risk-adjusted odds ratios of RLN injury and morbidity/mortality. RESULTS: Age ≥65, black race, neoplastic indication, total or subtotal thyroidectomy, concurrent neck surgery, operation time > median, hypoalbuminemia, and anemia were associated with RLN injury. Use of intraoperative nerve monitoring was associated with decreased RLN injuries. RLN injury is a risk factor for overall morbidity, hypocalcemia, hematoma, pulmonary morbidity, readmission, reoperation, and length of stay > median. CONCLUSION: Several predictors of RLN injury during thyroidectomy are identified, while use of intraoperative nerve monitoring was associated with a decreased risk of RLN injury. RLN injury is associated increased postoperative complications.

Endoscopic treatments for GERD.

Gastroesophageal reflux disease (GERD) is a condition with increasing prevalence and morbidity in the United States and worldwide. Despite advances in medical and surgical therapy over the last 30 years, gaps remain in the therapeutic profile of options. Flexible upper endoscopy offers the promise of filling in these gaps in a potentially minimally invasive approach. In this concise review, we focus on the plethora of endoluminal therapies available for the treatment of GERD. Therapies discussed include injectable agents, electrical stimulation of the lower esophageal sphincter, antireflux mucosectomy, radiofrequency ablation, and endoscopic suturing devices designed to create a fundoplication. As new endoscopic treatments become available, we come closer to the promise of the incisionless treatment of GERD. The known data surrounding the indications, benefits, and risks of these historical, current, and emerging approaches are reviewed in detail.

Achalasia: what to do in the face of failures of Heller myotomy.

Achalasia is a primary motility disorder of the esophagus, and while there are several treatment options, there is no consensus regarding them. When therapeutic intervention for achalasia fails, a careful evaluation of the cause of the persistent or recurrent symptoms using upper endoscopy, esophageal manometry, and contrast radiologic studies is required to understand the cause of therapy failure and guide plans for subsequent treatment. Options for reintervention are the same as for primary intervention and include pneumatic dilation, botulinum toxin injection, peroral endoscopic myotomy, or redo esophageal myotomy. When reintervention fails or if the esophagus is not amenable to intervention and the disease is considered end-stage, esophagectomy is the last option to manage recurrent achalasia.

Identifying Sources of Stress Across Years of General Surgery Residency.

Stressors during surgical residency training are common and can contribute to impaired technical performance, medical errors, health problems, physician burnout, and career turnover. This survey of general surgery recent graduates and chief residents examined threats to resident health and well-being. An electronic survey composed of multiple-choice, checkbox, dropdown, and open-ended questions was developed to determine the most stressful general surgery residency year, sources of the stress, and potential interventions to manage resident well-being. The survey was sent to five program directors across the United States to be forwarded to chief residents and recent graduates less than five years from graduation. Twenty-three residents and recent graduates responded to the survey. Seventy percent reported they "never" got enough sleep, and 39% reported they did not have a healthy lifestyle. Financial concerns were the most frequently cited source of stress. During post-graduate-years (PGY) 1 and 2, residents were most likely to fear hurting a patient or being "in over their head." In PGY-3, residents were most likely to consider leaving the residency program. The current findings suggest that each year of general surgery residency is linked with certain stressors, and no year is particularly stressful relative to the other years. There can be more research and efforts to focus on additional PGY-specific training and supervision, as well as added general measures to promote resident health and financial stability throughout all years. Regarding stress mitigation, residents may benefit from faculty, peer, and community interaction rather than from formal professional counseling.

Influence of Student Loan Debt on General Surgery Resident Career and Lifestyle Decision-Making.

BACKGROUND: The average medical school debt in 2011 was $170,000, and by 2017 it increased to $190,000. High debt burden has been shown to affect career choices for residents in primary care specialties; however, it has not been well studied among surgical residents. The purpose of this multi-institutional study was to assess the amount of debt among general surgery residents and its effects on their career and lifestyle decisions. STUDY DESIGN: Surveys were distributed to 607 categorical general surgery residents at 19 different residency programs. Degree of debt was assessed and responses compared. RESULTS: Overall, 427 (70.3%) residents completed the survey, 317 (74.2%) of whom reported having student loan debt. Of those with debt, 262 (82.6%) believed that repaying debt was a significant financial burden in residency, 248 (78.3%) thought it would remain a burden after residency, 210 (66.2%) believed their debt would influence their future job choice, and 225 (71%) thought their debt would delay their ability to buy a home. Debt did not affect decisions to get married or have children. There were 109 (25.6%) residents with no debt, 131 (30.8%) with <$200,000, 103 (24.2%) with $200,000 to $300,000, and 83 (19.5%) with >$300,000. Residents with high debt were less likely to feel financially secure now (p < 0.0001) and when thinking about their future (p < 0.0001). They also had higher minimum starting salary goals (p = 0.002) and were less likely to have had assistance paying for their education (p = 0.0001). CONCLUSIONS: Surgical residents believe their debt is a significant financial burden. Furthermore, high debt significantly influences their financial security, practice location, and salary goals.

Outcomes of robotic versus non-robotic minimally-invasive esophagectomy for esophageal cancer: An American College of Surgeons NSQIP database analysis.

BACKGROUND: Utilization of robotic-assistance for esophagectomy is increasing. The differences in outcomes between robotic-assisted minimally-invasive esophagectomy (RAMIE) and non-robotic minimally-invasive esophagectomy (MIE) for esophageal cancer are unknown. The purpose of this study was to compare 30-day postoperative outcomes between RAMIE and MIE. METHODS: A retrospective analysis was conducted using the ACS-NSQIP 2016-2017 databases. Primary outcome was 30-day postoperative mortality and morbidity. RESULTS: 725 minimally-invasive cases were identified, which included 100 RAMIE and 625 MIE. RAMIE was not found to be a risk factor for postoperative mortality (OR 1.50, 95% CI 0.38-6.00, p = 0.5675) or overall morbidity (OR 0.65, 95% CI 0.40-1.06, p = 0.0818). No significant differences were found between groups for systemic, organ-specific, or surgical complications. CONCLUSIONS: No significant difference was found in the incidence of 30-day postoperative outcomes between RAMIE and MIE. In comparison to MIE, RAMIE may be considered a feasible but non-superior option for treatment of esophageal cancer.

Career Goals, Salary Expectations, and Salary Negotiation Among Male and Female General Surgery Residents.

Importance: In general surgery, women earn less money and hold fewer leadership positions compared with their male counterparts. Objective: To assess whether differences exist between the perspectives of male and female general surgery residents on future career goals, salary expectations, and salary negotiation that may contribute to disparity later in their careers. Design, Setting, and Participants: This study was based on an anonymous and voluntary survey sent to 19 US general surgery programs. A total of 606 categorical residents at general surgery programs across the United States received the survey. Data were collected from August through September 2017 and analyzed from September through December 2017. Main Outcomes and Measures: Comparison of responses between men and women to detect any differences in career goals, salary expectation, and perspectives toward salary negotiation at a resident level. Results: A total of 427 residents (70.3%) responded, and 407 responses (230 male [58.5%]; mean age, 30.0 years [95% CI, 29.8-30.4 years]) were complete. When asked about salary expectation, female residents had lower expectations compared with men in minimum starting salary ($249 502 [95% CI, $236 815-$262 190] vs $267 700 [95% CI, $258 964-$276 437]; P = .003) and in ideal starting salary ($334 709 [95% CI, $318 431-$350 987] vs $364 663 [95% CI, $351 612-$377 715]; P < .001). Women also had less favorable opinions about salary negotiation. They were less likely to believe they had the tools to negotiate (33 of 177 [18.6%] vs 73 of 230 [31.7%]; P = .03) and were less likely to pursue other job offers as an aid in negotiating a higher salary (124 of 177 [70.1%] vs 190 of 230 [82.6%]; P = .01). Female residents were also less likely to be married (61 of 177 [34.5%] vs 116 of 230 [50.4%]; P = .001), were less likely to have children (25 of 177 [14.1%] vs 57 of 230 [24.8%]; P = .008), and believed they would have more responsibility at home than their significant other (77 of 177 [43.5%] vs 35 of 230 [15.2%]; P < .001). Men and women anticipated working the same number of hours, expected to retire at the same age, and had similar interest in holding leadership positions, having academic careers, and pursuing research. Conclusions and Relevance: This study found no difference in overall career goals between male and female residents; however, female residents' salary expectations were lower, and they viewed salary negotiation less favorably. Given the current gender disparities in salary and leadership within surgery, strategies are needed to help remedy this inequity.

Factors associated with general surgery residents' decisions regarding fellowship and subspecialty stratified by burnout and quality of life.

BACKGROUND: Although most surgery residents pursue fellowships, data regarding those decisions are limited. This study describes associations with interest in fellowship and specific subspecialties. METHODS: Anonymous surveys were distributed to 607 surgery residents at 19 US programs. Subspecialties were stratified by levels of burnout and quality of life using data from recent studies. RESULTS: 407 (67%) residents responded. 372 (91.4%) planned to pursue fellowship. Fellowship interest was lower among residents who attended independent or small programs, were married, or had children. Residents who received AOA honors or were married were less likely to choose high burnout subspecialties (trauma/vascular). Residents with children were less likely to choose low quality of life subspecialties (trauma/transplant/cardiothoracic). CONCLUSIONS: Surgery residents' interest in fellowship and specific subspecialties are associated with program type and size, AOA status, marital status, and having children. Variability in burnout and quality of life between subspecialties may affect residents' decisions.

Predictors of Robotic Versus Laparoscopic Inguinal Hernia Repair.

BACKGROUND: The advent of robotic-assisted surgery has added an additional decision point in the treatment of inguinal hernias. The goal of this study was to identify the patient, surgeon, and hospital demographic predictors of robotic inguinal hernia repair (IHR). METHODS: We conducted a retrospective analysis of 102,241 IHRs (1096 robotic and 101,145 laparoscopic) from 2010 through 2015 with data collected in the Premier Hospital Database. The adjusted odds ratio (OR) of receiving a robotic IHR was calculated for each of several demographic factors using multivariable logistic regression. RESULTS: The rate of robotic IHR increased from 2010 through 2015. Age <65 y and Charlson comorbidity index were not predictors of a robotic IHR. Females were more likely to receive a robotic IHR (OR 1.69, confidence interval [CI] 1.40-2.05, P < 0.0001). Compared with white patients, black patients were more likely (OR 1.33, CI 1.06-1.68, P = 0.0138), and other race patients were less likely (OR 0.47, CI 0.38-0.58, P < 0.0001) to receive a robotic IHR. Compared with Medicare insurance, patients with all other types of insurance were more likely to receive a robotic IHR (OR > 1.00, lower limit of CI > 1.00, P < 0.05). Higher volume surgeons were less likely to perform robotic IHR (OR < 1.00, upper limit of CI < 1.00, P < 0.05). Nonteaching (OR 1.81, CI 1.53-2.13, P < 0.0001), larger (OR > 1.00, lower limit of CI > 1.00, P < 0.05), and rural (OR 1.27, CI 1.03-1.57, P = 0.025) hospitals were more likely to perform robotic IHR. Significant regional variation in the rate of robotic IHR was identified (OR > 1.00, lower limit of CI > 1.00, P < 0.05). CONCLUSIONS: The rate of robotic IHR is increasing exponentially. This study found that female gender, black race, insurance other than Medicare, lower surgeon annual volume, larger hospital size, nonteaching hospital status, rural hospital location, and hospital region were predictors of robotic IHR.