Is the robotic revolution stunting surgical skills?

This perspective piece aims to examine the impact of the growing utilization of robotic platforms in general and minimally invasive surgery on surgical trainee experience, skill level, and comfort in performing general surgical and minimally invasive procedures following completion of training. We review current literature and explore the application of robotic surgery to surgical training, where minimum case thresholds and breadth distribution are well defined, and where development of surgical technique is historically gained through delicate tissue handling with haptic feedback rather than relying on visual feedback alone. We call for careful consideration as to how best to incorporate robotics in surgical training in order to embrace technological advances without endangering the surgical proficiency of the surgeons of tomorrow. Key message: The large-scale incorporation of robotics into general and minimally invasive surgical training is something that most, if not all, trainees must grapple with in today's world, and the proportion of robotics is increasing. This shift may significantly negatively affect trainees in terms of surgical skill upon completion of training and must be approached with an appropriate degree of concern and thoughtfulness so as to protect the surgeons of tomorrow.

Early Ambulation is Associated with Improved Outcomes Following Colorectal Surgery.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) society lists early mobilization as one of their recommendations for improving patient outcomes following colorectal surgery. The level of supporting evidence, however, is relatively weak, and furthermore, the ERAS guidelines do not clearly define "early" mobilization. In this study, we define mobilization in terms of time to first ambulation after surgery and develop an outcome-based cutoff for early mobilization. METHODS: This is a retrospective cohort study comprised of 291 patients who underwent colorectal operations at a large, academic medical center from June to December 2019. Three cutoffs (12 hours, 24 hours, and 48 hours) were used to divide patients into early and late ambulation groups for each cutoff, and statistical analysis was performed to determine differences in postoperative outcomes between the corresponding groups. RESULTS: Multivariate analysis showed no difference between the early and late ambulation groups for the 12-hour and 48-hour cutoffs; however, ambulation before 24 hours was associated with a decreased rate of severe complications as well as fewer adverse events overall. Patients who ambulated within 24 hours had a 4.1% rate of severe complications and a 22.1% rate of experiencing some adverse event (complication, return to the emergency department, and/or readmission). In comparison, 11.8% of patients who ambulated later experienced a severe complication (P = 0.026), while 36.1% of patients experienced some adverse event (P = 0.011). CONCLUSIONS: Ambulation within 24 hours after colorectal surgery is associated with improved postoperative outcomes, particularly a decreased rate of severe complications.

Variations in postoperative opioid prescribing by day of week and duration of hospital stay.

BACKGROUND: Studies demonstrate wide variation in postoperative opioid prescribing and that patients are at risk of chronic opioid abuse after surgery. The factors that influence prescribing, however, remain obscure. This study investigates whether day of the week or the postoperative day at the time of discharge impacts prescribing patterns. METHODS: We identified patients who underwent commonly performed procedures at our institution from January 2014 through April 2019 and analyzed the relationship between postoperative opioids prescribed (oral morphine milligram equivalents) and both the day of the week and the postoperative day at discharge. RESULTS: In ambulatory operations (n = 13,545), each day progressing from Monday was associated with increased morphine milligram equivalents prescribed on discharge (P = .0080). For inpatient cases (n = 10,838), surgeons prescribed more morphine milligram equivalents at discharge in the latter half of the week and during the weekend (P = .0372). Every additional postoperative day at discharge was associated with a +19.25 morphine milligram equivalent prescribed (P < .0001). CONCLUSION: More opioids were prescribed on discharges later in the week and after prolonged hospital stays perhaps to avoid patients running out of medication. Providers may unintentionally allow such non-clinical factors to influence postoperative opioid prescribing. Increased awareness of these inadvertent biases may help decrease excess prescribing of potentially addicting opioids after an operation.

Concussion Prevalence in Competitive Ultimate Frisbee Players.

BACKGROUND: Ultimate Frisbee (ultimate) is a fast-growing, popular sport played nationally by over 4 million athletes. While several studies have examined injury rates in ultimate, no work has investigated the prevalence of concussions specifically or players' knowledge and management of those injuries. PURPOSE: To estimate the lifetime prevalence of concussions in ultimate and to assess players' knowledge of concussions as well as their concussion management behaviors. STUDY DESIGN: Descriptive epidemiology study. METHODS: From June to November 2015, we collected ultimate-related concussion data via an anonymous web-based survey, the Concussion in Ultimate Frisbee Survey, from a convenience sample of 787 male and female ultimate players across the United States. RESULTS: There were 553 male and 234 female respondents included in the analysis; 26.58% of men and 24.79% of women reported that they had sustained at least 1 concussion while playing ultimate, with 45.58% and 43.10% of those men and women, respectively, reporting multiple concussions. A total of 67.81% of men and 78.21% of women stated that they would remove themselves from play after sustaining a given concussion, although 45.99% of men and 37.62% of women indicated that they had returned to play in the same game or practice. CONCLUSION: Our preliminary data suggest that concussions do commonly occur in competitive ultimate and that better education and management of concussions in ultimate athletes are needed. This study is an important first step in deepening our understanding of these issues.

Long-Term Patient-Reported Outcomes of Paraesophageal Hernia Repair.

BACKGROUND AND OBJECTIVES: There is a lack of consensus on the optimal repair technique and the definition of good outcomes in paraesophageal hernia (PEH) repair. We reviewed long-term patient-reported outcomes of open and laparoscopic PEH repair to assist with our future surgical consent process. METHODS: This was a retrospective case-control study including all patients with PEH repair performed from 2000 through 2012 at a single center without the use of mesh. We mailed questionnaires to patients to assess reoperation, symptom control, and satisfaction. RESULTS: Chart review identified 217 patients who underwent PEH repair. Nineteen died during the follow-up period. Of the 106 returning the questionnaire, 87 underwent laparoscopic repair, and 19 had open repair, with follow-up of 6.6 (SD 3.9) years and 7.0 (SD 4.1) years, respectively. Reoperation rates were 9.9% and 5.3%, respectively (P = .720). Dysphagia, heartburn, and regurgitation improved in 95.4% of patients after laparoscopic repair and 89.5% after open repair (P = .318). Medication for symptom control was necessary in 54.0% of patients after laparoscopic repair and 26.3% after open repair (P = .029). In each group, 90% stated that they would still choose to have the operation (P = .713). CONCLUSIONS: Long-term patient-specific outcomes showed comparable, encouraging results between open and laparoscopic repair of PEH without mesh reinforcement. However, half of those undergoing laparoscopic repair required the use of medication for symptom control. This study adds to the literature describing long-term patient-specific outcomes and can be useful when counseling patients about PEH repair.