Surgical treatment of preauricular fistulas: a 12-year single-center clinical observation.

OBJECTIVE: This study aimed to assess the effects of surgical timing and approach on operative duration, postoperative suture removal time, and postoperative recurrence rate in the management of preauricular fistula. A 12-year single-center clinical observation was conducted to analyze the potential effects of different surgical strategies on these critical outcomes. METHODS: The clinical data from 576 (782 ears) patients who underwent surgical resection for preauricular fistulas were examined in this retrospective study. The patients were classified into various groups based on differences in operative duration, surgical techniques and the use of intraoperative magnifying equipment. Furthermore, the specific data on operative duration, postoperative suture removal time, and postoperative recurrence rate were also recorded. RESULTS: The average operative duration for 782 ears and the average time required for postoperative suture removal were determined to be (34.57 ± 4.25) min and (3.62 ± 0.76) days, respectively. Among the cases examined, recurrence occurred in 13 ears, but all of them were cured after a second surgery, resulting in a recurrence rate of 1.67% (13/782). Interestingly, the operative and postoperative suture removal time was prolonged during the infection period (P < 0.05). The postoperative recurrence rate was significantly higher in the absence of magnifying equipment, as compared to those with the use of a microscope with 2.5× magnification (P < 0.05). No statistically significant differences were noted in the recurrence rate when comparing different anesthesia methods and types of surgical incisions, as well as the intraoperative use of methylene blue, and partial removal of cartilage of the pedicle (P > 0.05). CONCLUSION: The use of methylene blue, partial removal of the cartilage of the pedicle, and surgical incision during preauricular fistula resection did not affect the operative duration, postoperative suture removal time, and postoperative recurrence rate. Therefore, surgeons can select their preferred approaches based on their individual practices and patient-specific situations. However, the use of magnifying equipment during surgery is associated with a reduced risk of recurrence.

A data-driven approach to evaluate factors affecting resident performance in cataract surgery.

PURPOSE: To evaluate the operative duration and clinical performance of ophthalmology residents performing standard phacoemulsification cataract surgeries using information available from electronic health records (EHR). METHODS: This is a retrospective cohort study. De-identified surgical records of all standard phacoemulsifications performed in a tertiary institution between 1st January 2015 and 8th August 2018 were retrieved from the hospital EHR. The main outcome measures were improvement in operative duration with case experience, corrected distance visual acuity (CDVA) improvement, and intra-operative complication rates. RESULTS: Twelve ophthalmology residents performed a total of 1427 standard phacoemulsifications. The median operative duration was 27 min (interquartile range, 22-34 min), which improved from 31 to 24 min (before the 101st case [Group 1] versus 101st case onwards [Group 2], p < 0.001). Gradient change analysis (non-linear regression) showed significant reduction until the 100th case (p = 0.043). Older patients (0.019), worse pre-operative CDVA (0.343), and surgery performed by Group 1 (1.115) were significantly associated with operative duration above 30 min. LogMAR CDVA improved from a mean of 0.57 ± 0.52 pre-operatively to 0.10 ± 0.18 post-operatively (p < 0.001). Posterior capsule rupture (PCR) rate decreased from 4.0% [Group 1] to 2.1% [Group 2] (p = 0.096), while overall complication rate decreased from 8.9% to 3.1% (p < 0.001). CONCLUSION: The median operative duration reduced consistently with surgical experience for the first 100 cases. Older patients, poorer pre-operative VA, and surgical experience of less than 100 cases were significantly associated with an operative duration above 30 min. There was a statistically significant decrease in complication rate between Group 1 and 2.

The effect of operative duration on the outcome of colon cancer procedures.

BACKGROUND: Prolonged operative duration has been associated with increased post-operative morbidity in numerous surgical subspecialties; however, data are limited in operations for colon cancer specifically and existing literature makes unwarranted methodological assumptions of linearity. We sought to assess the effects of extended operative duration on perioperative outcomes in those undergoing segmental colectomy for cancer using a methodologically sound approach. METHODS: We conducted a retrospective cohort study of patients undergoing segmental colectomy for cancer between 2014 and 2018, logged in the National Surgical Quality Improvement Program datasets. Our primary outcome was a composite of any complication within 30 days; secondary outcomes included length of stay and discharge disposition. Our main factor of interest was operative duration. RESULTS: We analyzed 26,380 segmental colectomy cases, the majority of which were approached laparoscopically (64.95%) and were right sided (62.93%). Median operative duration was 152 (95% CI 112-206) minutes. On multivariable regression, increased operative duration was linearly associated with any complication (OR = 1.003, 95% CI 1.003-1.003, p < 0.0001) in the overall cohort, as was length of stay (p < 0.0001). All subgroups except for the laparoscopic left colectomy group were linearly associated with operative duration. In the laparoscopic left colectomy group, an inflection point in the odds of any complication was found at 176 min (OR = 1.39, 95% CI 1.20-1.61, p < 0.0001). CONCLUSIONS: This study suggests that the risk of perioperative complications increases linearly with increasing operative duration, where each additional 30 min increases the odds of complication by 10%. In those undergoing laparoscopic left colectomy, the risk of complications sharply increases after ~ 3 h, suggesting that surgeons should aim to complete these procedures within 3 h where possible.

Operative duration and short term morbidity and mortality following radical cystectomy with urinary diversion.

INTRODUCTION: To elucidate the association between operative duration (OD) and postoperative complications, which has been poorly studied in radical cystectomy. We hypothesize an increase in morbidity in radical cystectomy cases which have a longer OD. MATERIALS AND METHODS: Data from the National Surgical Quality Improvement Program (NSQIP) between the years 2012 and 2018 were reviewed for radical cystectomy with ileal conduit urinary diversion or continent diversion. Total operative time was divided into deciles and stratified comparisons were made using univariable and multivariable analysis. RESULTS: A total of 11,128 patients were examined. OD by minutes was stratified into the following deciles: 90-201, 202-237, 238-269, 270-299, 300-330, 331-361, 362-397, 398-442, 443-508, > 508. Operative times were shorter for patients with advanced age (p < 0.001), male gender (p < 0.001), low body mass index (BMI) (p < 0.001), bleeding diathesis (p = 0.019), COPD (p = 0.004), and advanced ASA class (p < 0.001). Complications significantly associated with prolonged OD included surgical site infection, urinary tract infection, sepsis/septic shock, renal failure and venous thromboembolism. On multivariate analysis, factors predictive of perioperative morbidity included presence of bleeding disorder (OR 1.70, 95% confidence intervals (CI) 1.37-2.12, p < 0.001), ASA Class IV-V compared to I-II (OR 2.26, 95% CI 1.89-2.72, p < 0.001), and prolonged operative time (tenth decile OR 3.05, 95% CI 2.55-3.66, ninth decile OR 2.11 95% CI 1.77-2.50, third decile OR 1.31, 95% CI 1.11-1.56, second decile OR 1.02, 95% CI 0.86-1.21 compared to first decile, p < 0.001) Conclusion: OD is an independent predictor of post-operative morbidity in patients undergoing radical cystectomy, even when adjusting for patient specific factors. Those patients within the longest decile had over 3-fold increase in the risk of morbidity compared to those with shorter OD.

Factors Affecting Residual Stone Rate, Operative Duration, and Complications in Patients Undergoing Minimally Invasive Percutaneous Nephrolithotomy.

Background and objectives: Although minimally invasive percutaneous nephrolithotomy (MPCNL) has demonstrated its efficacy, complete stone clearance was not always achieved, necessitating a second procedure. The purpose of this study was to evaluate factors associated with residual stone rate, operative duration, complications, and hospital stay, in order to develop algorithms for pre-operative prognosis and planning. Materials and Methods: This retrospective study involved 163 Bulgarian patients who underwent MPCNL with Holmium: YAG lithotripsy for the treatment of kidney stones. Patients were considered stone-free if no visible fragments (<3 mm) were found on nephroscopy at the end of the procedure, as well as on postoperative X-ray and abdominal ultrasound on the first postoperative day. Results: Immediate postoperative stone-free outcome was attained for 83.43% of the patients (136/163). Residuals were associated with staghorn stones (OR = 72.48, 95% CI: 5.76 to 91.81); stones in two locations (OR = 21.91, 95% CI: 4.15 to 137.56); larger stone size (OR = 1.12, 95% CI: 1.006 to 1.25); and higher density (OR = 1.03, 95% CI:1.005 to 1.06). The overall categorization accuracy for these factors was 93.80%, AUC = 0.971 (95% CI: 0.932 to 0.991), 89.71% sensitivity, and 96.30% specificity. Predictors of prolonged operative duration were staghorn stones and volume, R-square (adj.) = 39.00%, p < 0.001. Longer hospitalization was predicted for patients with hydronephrosis and staghorn stones, R-square (adj.) = 6.82%, p = 0.003. Post-operative complications were rare, predominantly of Clavien-Dindo Grade 1, and were more frequent in patients with hydronephrosis. We did not find a link between their occurrence and the outcome of MPCNL. Conclusions: Staghorn stones and stones in more than one location showed the strongest association with residual stone rate. Staghorn stones and larger volume were linked with a longer operative duration. Hydronephrosis increased the risk of complications and longer hospitalization.

The impact of operative duration and intraoperative fluid dynamics on postoperative hypocalcemia after total thyroidectomy: a prospective non-randomized study.

BACKGROUND: Postoperative hypocalcemia after total thyroidectomy (TT) still remains common. This prospective observation study examined the role of intraoperative time period (IOP) and intravenous fluids (IVF) in transient and permanent (> 6 months) hypocalcemia post-TT. SUBJECTS AND METHOD: Consecutive patients (n = 328; age = median (IQR); 34 (15) years; M:F = 65:263) with benign or malignant thyroid disease undergoing TT were evaluated for IOP, intraoperative IVF, serum corrected calcium, intact parathormone (iPTH), and 25-hydroxyvitamin D (25OHD) levels at baseline, 48 h, and 6 months post-TT. RESULTS: The incidence of symptomatic transient and permanent hypocalcemia post-TT was 33.5% and 7.9% respectively. In multivariate logistic regression analysis, the independent risk factors for transient hypocalcemia were IOP (odds ratio: 11.6), 48-h iPTH (4.8), IVF (2.9), hyperthyroidism (2.8), and percent calcium decline (1.07), while 25OHD deficiency increased the risk by 10.5 odds in subset with preoperative hypocalcemia. In receiver operating characteristic analysis, IOP, and IVF strongly predicted transient hypocalcemia with a threshold of 123 min and 1085 mL. Area under the curve, sensitivity, and specificity were 0.883 (95% CI: 0.838-0.928), 88.1%, and 74.4% and 0.883 (0.840-0.926; each P = 0.001), 84.4%, and 74.4% respectively. Serum 48-h calcium < 7.8 mg/dL was the only reliable predictor of permanent hypocalcemia. CONCLUSION: Operative duration > 123 min and IVF > 1085 mL increased the risk of transient hypocalcemia post-TT manyfold but not permanent hypocalcemia. Routine intraoperative identification, preservation of viable in situ parathyroid glands, and laryngeal nerves increased IOP and rates of transient hypocalcemia but improved long-term outcome.

Operative Duration and Short-Term Postoperative Complications after Unicompartmental Knee Arthroplasty.

BACKGROUND: Prolonged operative duration is an independent risk factor for postoperative complications in many orthopedic procedures ranging from shoulder arthroscopy to total hip and knee arthroplasties. It has not been well studied in unicompartmental knee arthroplasty (UKA). The purpose of this study is to assess the effect of operative duration on complications after UKA. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program registry, we identified all primary unilateral UKAs from 2005 to 18. Patients were divided into three cohorts based on the operative duration: < 90 minutes, between 90 and 120 minutes, and >120 minutes. Baseline patient and operative demographics (age, gender, etc.) and thirty-day complications were compared using bivariate analysis. Multivariate analysis was used to assess the independent effect of operative duration on postoperative outcomes after adjusting for differences in baseline characteristics. RESULTS: We identified 11,806 patients who underwent primary UKA from 2005 to 18. There was no difference in the "any complication" rate between cohorts. However, operative duration >120 minutes was associated with a significantly higher likelihood of reoperation (odds ratio [OR] 2.02, 95% confidence interval [CI]: 1.15-3.57, P = .015), non-home discharge (OR: 2.14, CI: 1.65-2.77, P < .001), surgical site infection (OR: 1.76, CI: 1.03-3.01, P = .038), and blood transfusions (OR: 3.23, CI: 1.44-7.22, P = .004) when compared with operative duration <90 minutes. There was no difference in mortality rates. CONCLUSION: Increased operative duration greater than 2 hours in primary UKA is associated with an increased risk of non-home discharge, surgical site infection, reoperation, and blood transfusion.

Analysis of risk factors of postlaparoscopic shoulder pain.

AIM: Postlaparoscopic shoulder pain (SP), mainly caused by pneumoperitoneum with CO2 , sometimes suffers patients. This study was aimed to analyze the backgrounds of SP after gynecologic laparoscopy to clarify the risk of SP. METHODS: We analyzed answers of questionnaire about the degree of SP from 696 patients undergoing gynecologic laparoscopic surgery since 2014-2018. The questionnaire asks the degree of SP with numeric rating scale from 0 to 10, before and 3 days after operation. We defined cases in which postoperative score elevated more than three compared to preoperative score as SP(+). Analyzed backgrounds were age, parity, body mass index, operative method, operative duration and amount of hemorrhage. Statistics was performed by Fisher exact analysis as univariate analysis, and with logistic regression as multivariate analysis. All laparoscopic surgeries were performed under 10-12 mmHg in pressure of pneumoperitoneum with CO2 . RESULTS: Univariate analysis revealed categories 'less than 50 years old', and 'over 2 h' and 'over 3 h' in operative duration resulted significant high rate of SP(+). For these three factors, multivariate analysis resulted that "less than 50 years old' and 'over 3 h in operative duration' were significantly high. CONCLUSION: This study suggests that 'less than 50 years' old and 'over 3 h in operative duration' were risk factors of postlaparoscopic SP. To protect from SP after laparoscopy, some countermeasures should be necessary especially for these patients.

Procedure length is independently associated with overnight hospital stay and 30-day readmission following anterior cruciate ligament reconstruction.

PURPOSE: The purpose was to characterize the independent effect of procedure length on the rates of 30-day perioperative complications, hospital readmissions, and overnight hospital stay in patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR). We hypothesized that longer procedure length in primary ACLR increases the risk for post-operative complications. METHODS: Primary ACLR cases from 2005 to 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Patients were categorized into two cohorts based on procedure length, either less than or greater than 90 min. Two equal-sized propensity-matched cohorts were generated to account for differences in baseline and operative characteristics. Thirty-day clinical outcomes were compared using bivariate analyses between propensity-matched groups that controlled for patient-specific factors and concurrent meniscal repair. Multivariate logistic regression models were used to identify independent predictors of hospital readmission and overnight hospital stay. RESULTS: In total, 12,077 ACLR cases were identified. The rate of any 30-day complication was increased in longer procedures relative to shorter procedures (1.6% vs 0.9%, p = 0.006), as were the rates of returning to the operating room (0.6% vs 0.3%, p = 0.03), hospital readmission (1.0% vs 0.3%, p = 0.001), and overnight hospital stay (16.2% vs 6.0%, p < 0.001). Obesity was a risk factor for both hospital readmission and overnight hospital stay, while hypertension, diabetes, chronic obstructive pulmonary disease, and a smoking history were associated with increased rates of overnight hospital stay. The most common reasons for hospital readmission were deep vein thrombosis or pulmonary embolism (25.0% of all readmitted patients), surgical site infection (25.0%), and post-operative pain (14.1%). CONCLUSIONS: In this propensity-matched analysis adjusting for baseline patient characteristics and operative factors, procedure length of greater than or equal to 90 min in ACLR was independently associated with an increased risk of hospital readmission and overnight hospital stay. As a surrogate measure of surgical complexity, operative time may be a useful perioperative variable for post-operative risk stratification and patient counseling. LEVEL OF EVIDENCE: III.

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy.

BACKGROUND: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. METHODS: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. RESULTS: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45-85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p < 0.001), with the proportions of operations lasting > 90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. CONCLUSION: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care.

A prospective study of evaluation of operative duration as a predictor of mortality in pediatric emergency surgery: Concept of 100 minutes laparotomy in resource-limited setting.

INTRODUCTION: Operative duration is an important but under-studied predictor of mortality in emergency laparotomies. AIMS AND OBJECTIVES: The primary objective of this study was to quantify the effect of duration of emergency laparotomy in children on mortality; and to identify a rough cut-off duration of laparotomy to serve as a guide so that a laparotomy can be planned to optimize pediatric surgical patient outcome. MATERIALS AND METHODS: This is a prospective study conducted in a government tertiary teaching institution over a period of 24 months. All children in the age group of 5-10 years presenting in the emergency department with Pediatric Risk of Mortality III score ≤8, undergoing emergency laparotomy in emergency operation theater, were included. OBSERVATIONS AND RESULTS: In all, 213 children were included in the study. The mean time from presentation to shifting to the operating room was 3.7 h. The mean operative duration was 108 min. The mean operative time in survived patients was 102 min as compared to 135 min in expired patients (P < 0.05). The 30-day in-hospital mortality rate was 17.4%. After application of binary logistic regression analysis, it was found that time to laparotomy and operative duration were significant risk factors (<0.05) predicting post-operative mortality. Kaplan-Meier survival curve showed a decrease at a mean weighted operative duration of approximately 100 min. Receiver operating characteristic curve analysis yielded operative duration of 123.5 min at which Youden's index maximized. CONCLUSION: This 100-min duration of laparotomy might appear a long duration but in casualty setup of a government hospital with limited resources, there are so many hurdles for optimal working that completion of an emergency laparotomy in children in 100 min can be considered a realistic target for improving post-operative outcome. At an operative duration of <123.50 min, mortality rates within acceptable limits can be achieved.

The use of patient factors to improve the prediction of operative duration using laparoscopic cholecystectomy.

BACKGROUND: Reliable prediction of operative duration is essential for improving patient and care team satisfaction, optimizing resource utilization and reducing cost. Current operative scheduling systems are unreliable and contribute to costly over- and underestimation of operative time. We hypothesized that the inclusion of patient-specific factors would improve the accuracy in predicting operative duration. METHODS: We reviewed all elective laparoscopic cholecystectomies performed at a single institution between 01/2007 and 06/2013. Concurrent procedures were excluded. Univariate analysis evaluated the effect of age, gender, BMI, ASA, laboratory values, smoking, and comorbidities on operative duration. Multivariable linear regression models were constructed using the significant factors (p < 0.05). The patient factors model was compared to the traditional surgical scheduling system estimates, which uses historical surgeon-specific and procedure-specific operative duration. External validation was done using the ACS-NSQIP database (n = 11,842). RESULTS: A total of 1801 laparoscopic cholecystectomy patients met inclusion criteria. Female sex was associated with reduced operative duration (-7.5 min, p < 0.001 vs. male sex) while increasing BMI (+5.1 min BMI 25-29.9, +6.9 min BMI 30-34.9, +10.4 min BMI 35-39.9, +17.0 min BMI 40 + , all p < 0.05 vs. normal BMI), increasing ASA (+7.4 min ASA III, +38.3 min ASA IV, all p < 0.01 vs. ASA I), and elevated liver function tests (+7.9 min, p < 0.01 vs. normal) were predictive of increased operative duration on univariate analysis. A model was then constructed using these predictive factors. The traditional surgical scheduling system was poorly predictive of actual operative duration (R 2 = 0.001) compared to the patient factors model (R 2 = 0.08). The model remained predictive on external validation (R 2 = 0.14).The addition of surgeon as a variable in the institutional model further improved predictive ability of the model (R 2 = 0.18). CONCLUSION: The use of routinely available pre-operative patient factors improves the prediction of operative duration during cholecystectomy.

Operative duration as independent predictor of increased postoperative healthcare utilization.

PURPOSE: Few studies have examined the risk factors for postoperative healthcare resource utilization (HRU) among minimally invasive partial nephrectomy (MIPN), minimally invasive prostatectomy (MIP), and cystectomy (Cx). The aim of this study is to assess if operative duration (OD) is a predictor of HRU in this population. METHODS: The ACS-NSQIP database was filtered for MIPN, MIP, and Cx. Patient characteristics and intraoperative variables were examined. HRU was defined as prolonged length of stay (LOS), unplanned readmission within 30 days, and discharge to continued care facility. Multivariate regression analysis was used to identify independent predictors of HRU. RESULTS: 18,904 MIPN, 50,807 MIP, and 12,451 Cx were included. For MIPN, HRU was seen in 13.9% of cases < 1.75 h, increasing to 36.2% in OD > 4.5 h (p < 0.001). For MIP, HRU was seen in 10.6% of OD < 2 h, increasing to 32.2% for OD > 4.9 h (p < 0.001). For Cx, 57% of those with OD > 8.5 h required HRU compared to 42.1% for OD < 3.3 h (p < 0.001). On multivariate analyses, OD was an independent predictor for increased HRU for all procedures regardless of patient characteristics or comorbidities. For MIPN, OD > 4.5 h had 3.5-fold increased use of HRU (p < 0.001). For MIP, OD > 5 h had 3.7-fold increased use of HRU (p < 0.001). For Cx, OD > 8.5 h demonstrated a twofold increased use of HRU (p < 0.001). CONCLUSIONS: OD during MIPN, MIP, and Cx is an independent predictor of increased HRU irrespective of patient comorbidities. Patients with OD > 4.5 h for MIPN, > 5 h for MIP, and > 8.5 h for Cx have 3.5-fold, 3.7-fold, and twofold increased risk of HRU, respectively.

Application of nonpenetrating titanium clips for primary spinal dural closure following intradural tethered cord release in pediatric tethered cord syndrome: Profile of safety, efficacy, efficiency, and complications.

Introduction: Surgical treatment for tethered cord syndrome (TCS) involves a laminotomy for intradural lysis of filum terminale (LFT), with the goal of releasing excess tension on the conus medullaris by dividing the filum terminale. While LFT alleviates clinical symptoms, it is associated with risks and complications, including cerebrospinal fluid (CSF) leak and infection, either superficial or deep. Some risks and complications of LFT relate to efficiency and quality of primary dural closure and its downstream effects. We sought to assess the utility of nonpenetrating titanium clips (TC) for primary dural closure with a particular focus on operative duration, associated costs, and complication profiles in a series of pediatric patients undergoing LFT, hypothesizing that TC utilization leads to more efficient closure and therefore potentially lower costs and potentially associated anesthetic length and risks. Methods: A 4-surgeon, single institution series of 28 pediatric patients underwent LFT with subsequent dural closure performed with either the AnastoClip® nonpenetrating titanium clips or traditional suture technique between July 2022 and May 2023. In order to compare the safety, efficacy, and cost-effectiveness between the two dural closure techniques, relevant data were collected including patient demographics and rates of CSF leak, infection at three-month follow-up, and reoperation. Operative durations and times from beginning to end of dural closure were recorded. Results: A total of 28 pediatric patients (mean age: 5.9 years, 43% female, range: 0.71-17 years) with TCS underwent LFT. All patients underwent procedures involving intradural surgery of the lumbar region. Dural closure was performed using traditional suturing in 19 patients (67.9%) and TC in 9 (32.1%). With respect to duration of dural closure, the average time to closure using traditional suturing techniques was 1271 s (or 21 min and 11 s), while the average time for TC was 265 s (or 4 min and 25 s). At three-month follow-up, one case of cerebrospinal fluid (CSF) leak or infection was observed in the suture cohort and required reoperation. Conclusion: Clinical outcomes in the TC group were excellent, consistent with previous reports; our findings further suggest that TCs result in more efficient dural closure than traditional suturing techniques. Our findings suggest that TC may be a safe, efficacious, and more efficient alternative to traditional suture for achieving dural closure in pediatric patients with TCS undergoing LFT surgery.

The impact of minimally-invasive esophagectomy operative duration on post-operative outcomes.

Background: Esophagectomy, an esophageal cancer treatment mainstay, is a highly morbid procedure. Prolonged operative time, only partially predetermined by case complexity, may be uniquely harmful to minimally-invasive esophagectomy (MIE) patients for numerous reasons, including anastomotic leak, tenuous conduit perfusion and protracted single-lung ventilation, but the impact is unknown. This multi-center retrospective cohort study sought to characterize the relationship between MIE operative time and post-operative outcomes. Methods: We abstracted multi-center data on esophageal cancer patients who underwent MIE from 2010 to 2021. Predictor variables included age, sex, comorbidities, body mass index, prior cardiothoracic surgery, stage, and neoadjuvant therapy. Outcomes included complications, readmissions, and mortality. Association analysis evaluated the relationship between predictor variables and operative time. Multivariate logistic regression characterized the influence of potential predictor variables and operative time on post-operative outcomes. Subgroup analysis evaluated the association between MIE >4 h vs. ≤4 h and complications, readmissions and survival. Results: For the 297 esophageal cancer patients who underwent MIE between 2010 and 2021, the median operative duration was 4.8 h [IQR: 3.7-6.3]. For patients with anastomotic leak (5.1%) and 1-year mortality, operative duration was elevated above the median at 6.3 h [IQR: 4.8-8.6], p = 0.008) and 5.3 h [IQR: 4.4-6.8], p = 0.04), respectively. In multivariate logistic regression, each additional hour of operative time increased the odds of anastomotic leak and 1-year mortality by 39% and 19%, respectively. Conclusions: Esophageal cancer is a poor prognosis disease, even with optimal treatment. Operative efficiency, a modifiable surgical variable, may be an important target to improve MIE patient outcomes.

Continuous Relationship of Operative Duration with Risk of Adverse Perioperative Outcomes and Early Discharge Undergoing Thoracoscopic Lung Cancer Surgery.

Background: For thoracoscopic lung cancer surgery, the continuous relationship and the trigger point of operative duration with a risk of adverse perioperative outcomes (APOs) and early discharge remain unknown. Methods: This study enrolled 12,392 patients who underwent this surgical treatment. Five groups were stratified by operative duration: <60 min, 60−120 min, 120−180 min, 180−240 min, and ≥240 min. APOs included intraoperative hypoxemia, delayed extubation, postoperative pulmonary complications (PPCs), prolonged air leakage (PAL), postoperative atrial fibrillation (POAF), and transfusion. A restricted cubic spline (RCS) plot was used to characterize the continuous relationship of operative duration with the risk of APOs and early discharge. Results: The risks of the aforementioned APOs increased with each additional hour after the first hour. A J-shaped association with APOs was observed, with a higher risk in those with prolonged operative duration compared with those with shorter values. However, the probability of early discharge decreased from 0.465 to 0.350, 0.217, and 0.227 for each additional hour of operative duration compared with counterparts (<60 min), showing an inverse J-shaped association. The 90 min procedure appears to be a tipping point for a sharp increase in APOs and a significant reduction in early discharge. Conclusions: Our findings have important and meaningful implications for risk predictions and clinical interventions, and early rehabilitation, for APOs.

Identification of an Operative Time Threshold for Substantially Increased Postoperative Complications Among Elderly Spine Surgery Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To identify whether thresholds exist beyond which operative duration or age increases risks for complications among patients ≥65 years undergoing elective spine surgery. METHODS: Elective inpatient spine procedures unrelated to infection/trauma/tumor diagnoses in patients <65 years recorded in the 2006-2019 American College of Surgeons National Surgical Quality Improvement database were identified. Univariate analyses was used to compare 30 day complication rates among 5 operative duration and age-stratified groups. To quantify the risk of prolonged operative duration on complications, multivariate analyses were performed controlling for confounders. A generalized linear model was used to assess the individual and combined effect strength of age and operative duration on complication rates. RESULTS: Among 87,705 patients stratified by operative duration, 30 day complication rates rose nonlinearly as operative duration increased, with a sharp rise after 4.0-4.9 hours (28.3% at 4.0-4.9 hours, 51.7% at ≥5 hours, P < .001). Multivariate analysis found operative duration was independently associated with increased risk of overall complications (odds ratio 1.10→1.69, P < .001) and medical complications (odds ratio 1.19→1.98, P < .001). Although complication rates rose by age (all P < .001), age was not independently predictive of overall complications within any operative duration group on multivariate analysis. Operative duration had a greater effect (η2P = .067) than age (η2P = .003) on overall complication rates. CONCLUSIONS: Increased operative duration was strongly associated with 30 day complication rates, particularly beyond a threshold of 5 hours. Furthermore, operative duration had a notably larger effect on overall complication rates than age.

Impact of Prolonged Operative Duration on Postoperative Symptomatic Venous Thromboembolic Events After Thoracolumbar Spine Surgery.

OBJECTIVE: To determine the effect of operative duration on the rate of postoperative symptomatic venous thromboembolic (VTE) events in patients undergoing thoracolumbar spine fusion. METHODS: We identified all thoracolumbar spine fusion patients between 2012 and 2021. Operative duration was defined as time from skin incision to skin closure. A 1:1 propensity match was conducted incorporating patient and surgical characteristics. Logistic regression was performed to assess predictors of postoperative symptomatic VTE events. A receiver operating characteristic curve was created to determine a cutoff time for increased likelihood of VTE. RESULTS: We identified 101 patients with VTE and 1108 patients without VTE. Seventy-five patients with VTE were matched to 75 patients without VTE. Operative duration (339 vs. 262 minutes, P = 0.010) and length of stay (5.00 vs. 3.54 days, P = 0.008) were significantly longer in patients with a VTE event. Operative duration was an independent predictor of VTE on multivariate regression (odds ratio: 1.003, 95% confidence interval: 1.001-1.01, P = 0.021). For each additional hour of operative duration, the risk of VTE increased by 18%. A cutoff time of 218 minutes was identified (area under the curve [95% confidence interval] = 0.622 [0.533-0.712]) as an optimal predictor of increased risk for a VTE event. CONCLUSIONS: Operative duration significantly predicted symptomatic VTE, especially after surgical time cutoff of 218 minutes. Each additional hour of operative duration was found to increase VTE risk by 18%. We also identify the impact of VTE on 90-day readmission rates, suggesting significantly higher costs and opportunity for hospital acquired conditions, in line with prior literature.

Determinants of Operative Time in Arthroscopic Rotator Cuff Repair.

Arthroscopic rotator cuff repairs have been reported to take between 72 and 113 min to complete. This team has adopted its practice to reduce rotator cuff repair times. We aimed to determine (1) what factors reduced operative time, and (2) whether arthroscopic rotator cuff repairs could be performed in under 5 min. Consecutive rotator cuff repairs were filmed with the intent of capturing a <5-min repair. A retrospective analysis of prospectively collected data of 2232 patients who underwent primary arthroscopic rotator cuff repair by a single surgeon was performed using Spearman's correlations and multiple linear regression. Cohen's f2 values were calculated to quantify effect size. Video footage of a 4-min arthroscopic repair was captured on the 4th case. Backwards stepwise multivariate linear regression found that an undersurface repair technique (f2 = 0.08, p < 0.001), fewer surgical anchors (f2 = 0.06, p < 0.001), more recent case number (f2 = 0.01, p < 0.001), smaller tear size (f2 = 0.01, p < 0.001), increased assistant case number (f2 = 0.01, p < 0.001), female sex (f2 = 0.004, p < 0.001), higher repair quality ranking (f2 = 0.006, p < 0.001) and private hospital (f2 = 0.005, p < 0.001) were independently associated with a faster operative time. Use of the undersurface repair technique, reduced anchor number, smaller tear size, increased surgeon and assistant surgeon case number, performing repairs in a private hospital and female sex independently lowered operative time. A <5-min repair was captured.

The impact of case order and intraoperative staff changes on spine surgical efficiency.

BACKGROUND CONTEXT: Despite concerted efforts toward quality improvement in high-volume spine surgery, there remains concern that increases in case load may compromise the efficient and safe delivery of surgical care. There is a paucity of evidence to describe the effects of spine case order and operating room (OR) team structure on measures of intraoperative timing and OR efficiency. PURPOSE: This study aims to determine if intraoperative staff changes and surgical case order independently predict extensions in intraoperative timing after spinal surgery for spondylotic diseases. STUDY DESIGN/ SETTING: Retrospective cohort analysis PATIENT SAMPLE: All patients over age 18 who underwent primary or revision decompression and/or fusion for degenerative spinal diseases between 2017 to 2019 at a single academic institution were retrospectively identified. Exclusion criteria included absence of descriptive data and intraoperative timing parameters as well as surgery for traumatic injury, infection, and malignancy. OUTCOME MEASURES: Intraoperative timing metrics including total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. Postoperative outcomes included length of hospital stay and 90-day hospital readmissions. METHODS: Surgical case order and intraoperative changes in staff (circulator and surgical scrub nurse or technician) were determined. Patient demographics, surgical factors, intraoperative timing and postoperative outcomes were recorded. Extensions in each operative stage were determined as a ratio of the actual duration of the parameter divided by the predicted duration of the parameter. Univariate and multivariate analyses were performed to compare outcomes within case order and staff change groups. RESULTS: A total of 1,108 patients met the inclusion criteria. First, second, and third start cases differed significantly in intraoperative extensions of total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. On regression, decreasing case order predicted extension in wheels in to induction time. Surgeries with intraoperative staff changes were associated with increases in total theater time, induction start to cut time, cut to close time, close to wheels out time, and length of hospital stay. Switch in primary circulator predicted extended theater time and cut to close time. Relief of primary circulator or scrub predicted extended total theater time, induction start to cut time, cut to close time, and close to wheels out time. CONCLUSIONS: Intraoperative staff change in spine surgery independently predicted extended operative duration. However, higher case order was not significantly associated with procedural time.