Completeness of operative reports for rectal cancer surgery

An assessment of narrative operative reports for Wilms tumor resection using consensus component criteria

INTRODUCTION

Precision in surgical documentation is essential to avoid miscommunication and errors in patient care. Synoptic operative reports are more precise than narrative operative reports, however they have not been widely implemented in pediatric surgical oncology. To assess the need for implementation of synoptic operative reports in pediatric surgical oncology, we examined the completeness of narrative operative reports in patients undergoing resection of Wilms tumor.

METHODS

We conducted a retrospective review of narrative operative reports for resection of Wilms tumor at a single pediatric oncology center from January 2022 through July 2023. Primary outcomes were the presence or absence of 11 key operative report components. Inclusion rates were calculated as simple percentages. Unilateral and bilateral operations were considered.

RESULTS

Thirty-five narrative reports for Wilms tumor resection were included. The most consistently documented operative report components were estimated blood loss, indication for surgery, intraoperative complications, and specimen naming (100% documentation rates). Documentation of lymph node sampling was present in 94.3% of reports. The least consistently documented components were assessment of intraoperative tumor spillage, completeness of resection, metastatic disease, and assessment of vascular involvement (each ≤40% documentation rate). All 11 key components were documented in three reports.

CONCLUSIONS

Even at a large tertiary pediatric oncology referral center, narrative operative reports for pediatric Wilms tumor resection were found to be frequently missing important components of surgical documentation. Often, these were omissions of negative findings. Utilization of synoptic operative reports may be able to reduce these gaps.

Documentation of critical intraoperative oncologic findings: Synoptic versus narrative operative reports for childhood cancer surgery

BACKGROUND

Documentation of intraoperative oncologic findings varies greatly across narrative operative reports (NRs). An international panel of childhood cancer experts recently developed a synoptic operative report (SR) for childhood cancer surgeries. The aim of this study was to compare the documentation of critical intraoperative findings in NRs versus SRs.

METHODS

A single-center retrospective review of all surgical resections of primary solid tumors at our pediatric oncology center was conducted from June 2023 to March 2024, after an institutional SR was piloted from October 2023 onwards. Data collected included the presence or absence of six components included in standard pediatric oncology NRs. Inclusion rates were calculated as percentages for each component. Due to the small sample, the Fisher's exact test was used for all hypothesis testing.

RESULTS

Seventy primary tumor resections were performed during the study period, as documented by 38 NRs and 32 SRs. All operative reports after October 2023 were SRs. Completeness of tumor resection and specimen naming were consistently documented in NRs (86% and 100%, respectively) and SRs (100% and 100%, respectively). The presence/absence of three components-intraoperative tumor spillage (31%), vascular involvement (31%), and lymph node sampling (26%)-were documented in fewer than a third of the NRs. Documentation of the presence/absence of locoregional spread, intraoperative tumor spillage, vascular involvement, and lymph node sampling was significantly better in SRs than in NRs.

CONCLUSION

Adoption of SRs significantly improved the documentation of critical intraoperative findings. Thus, we recommend using SRs in pediatric solid tumor surgery.

Development of a Consensus-Derived Synoptic Operative Report for Rectal Prolapse: A Report From the Pelvic Floor Disorders Consortium

BACKGROUND

Narrative operative reports may omit or obscure data from an operation.

OBJECTIVE

To develop a synoptic operative report for rectal prolapse that includes core descriptors as developed by an international consensus of expert pelvic floor surgeons.

DESIGN

Descriptors for patients undergoing rectal prolapse surgery were generated through review. Members of the Pelvic Floor Disorders Consortium were recruited to participate in a 3-round Delphi process using a 9-point Likert scale. Descriptors that achieved 70% agreement were kept from the first round, and descriptors scoring 40% to 70% agreement were recirculated in subsequent rounds. A final list of operative descriptors was determined at a consensus meeting, with a final consensus meeting more than 70% agreement.

SETTINGS

This survey was administered to members of the Pelvic Floor Disorders Consortium.

PATIENTS

No patient data are included in this study.

MAIN OUTCOME MEASURES

Descriptors meeting greater than 70% agreement were selected.

RESULTS

One hundred seventy-six surgeons representing colorectal surgeons, urogynecologists, and urologists distributed throughout North America (56%), Latin America (4%), Western Europe (29%), Asia (4%), and Africa (1%) participated in the first round of Delphi voting. After 2 additional rounds and a final consensus meeting, 16 of 30 descriptors met 70% consensus. Descriptors that met consensus were surgery type, posterior dissection, ventral dissection, mesh used, type of mesh used, mesh location, sutures used, suture type, pouch of Douglas and peritoneum reclosed, length of rectum imbricated, length of bowel resected, levatoroplasty, simultaneous vaginal procedure, simultaneous gynecologic procedure, simultaneous enterocele repair, and simultaneous urinary incontinence procedure.

LIMITATIONS

The survey represents the views of members of the Delphi panel and may not represent the viewpoints of all surgeons.

CONCLUSIONS

This Delphi survey establishes international consensus descriptors for intraoperative variables that have been used to produce a synoptic operative report. This will help establish defined operative reporting to improve clinical communication, quality measures, and clinical research. See Video Abstract .

DESARROLLO DE UN PROTOCOLO OPERATORIO SINPTICO DERIVADO DE CONSENSO PARA EL PROLAPSO RECTAL UN INFORME DEL CONSORCIO DE TRASTORNOS DEL PISO PLVICO

ANTECEDENTES:Los protocolos operativos narrativos frecuentemente pueden omitir u oscurecer datos de un procedimiento.OBJETIVO:Nuestro objetivo es desarrollar un protocolo operatorio sinóptico para el prolapso rectal que incluya descriptores básicos desarrollados por un consenso internacional de cirujanos expertos en piso pélvico.DISEÑO:Los descriptores para pacientes sometidos a cirugía de prolapso rectal se generaron mediante revisión. Se reclutó a miembros del Consorcio de Trastornos del Piso Pélvico para participar en un proceso Delphi de 3 rondas utilizando una escala Likert de 9 puntos. Los descriptores que lograron un 70% de acuerdo se mantuvieron en la primera ronda, los descriptores que obtuvieron un 40-70% de acuerdo se recircularon en rondas posteriores. Se determinó una lista final de descriptores operativos en una reunión de consenso, con una reunión de consenso final de más del 70% de acuerdo.ESCENARIO:Esta fue una encuesta administrada a miembros del Consorcio de Trastornos del Piso Pélvico.PRINCIPALES MEDIDAS DE RESULTADO:Se seleccionaron los descriptores que cumplieron más del 70% de acuerdo.RESULTADOS:Ciento setenta y seis cirujanos en representación de cirujanos colorrectales, uroginecólogos y urólogos distribuidos en América del Norte (56%), América Latina (4%), Europa Occidental (29%), Asia (4%) y África (1%) participaron en la primera ronda de votación Delphi. Después de dos rondas adicionales y una reunión de consenso final, 16 de 30 descriptores alcanzaron un 70% de consenso. Los descriptores que alcanzaron consenso fueron: tipo de cirugía, disección posterior, disección ventral, malla utilizada, tipo de malla utilizada, ubicación de la malla, suturas utilizadas, tipo de sutura, cierre del fondo de saco de Douglas y peritoneo, longitud del recto superpuesto, longitud del intestino resecado, plastía de los elevadores , procedimiento vaginal simultáneo, procedimiento ginecológico simultáneo, reparación simultánea de enterocele y procedimiento simultáneo de incontinencia urinaria.LIMITACIONES:La encuesta representa las opiniones de los miembros del panel Delphi y puede no representar los puntos de vista de todos los cirujanos.CONCLUSIONES/DISCUSIÓN:Esta encuesta Delphi establece descriptores de consenso internacional para las variables intraoperatorias que se han utilizado para producir un protocolo operatorio sinóptico. Esto ayudará a establecer protocolos operativos definidos para mejorar la comunicación clínica, las medidas de calidad y la investigación clínica. (Traducción-Dr. Felipe Bellolio ).

Synoptic operative reports for pediatric surgical oncology

Synoptic operative notes for pediatric surgical oncology provide standardized and structured documentation of surgical procedures performed on pediatric patients with cancer. These reports capture essential details such as preoperative diagnosis, intraoperative findings, surgical technique, and tumor characteristics in a concise and uniform format. By promoting consistency, accuracy, and completeness in reporting, synoptic operative notes facilitate effective communication among multidisciplinary healthcare teams, enhance quality assurance efforts, and streamline data extraction for research purposes. The integration of synoptic reporting within electronic medical record systems further enhances accessibility and usability, ensuring efficient documentation practices and improved patient care outcomes in pediatric surgical oncology.

Adequate Reporting Among Ventral Hernia Repair Operative Reports: A Cross-Sectional Study of Prevalence of Details and Association With Clinical Outcomes

Objective

We aimed to evaluate the prevalence of highly detailed ventral hernia repair (VHR) operative reports and associations between operative report detail and postoperative outcomes in a medico-legal dataset.

Background

VHR are one of the most common surgical procedures performed in the United States. Previous work has shown that VHR operative reports are poorly detailed, however, the relationship between operative report detail and patient outcomes is unknown.

Methods

This is a retrospective cross-sectional observational study. Operative reports describing VHR were obtained from a medical-legal database. Medical records were screened and data was extracted including clinical outcomes, such as surgical site infection (SSI), hernia recurrence, and reoperation and the presence of key details in each report. Highly detailed operative reports were defined as having 70% of recommended details. The primary outcome was the prevalence of highly detailed VHR operative reports.

Results

A total of 1011 VHR operative reports dictated by 693 surgeons across 517 facilities in 50 states were included. Median duration of follow-up was 4.6 years after initial surgery. Only 35.7% of operative reports were highly detailed. More recent operative reports, cases with resident involvement, and contaminated procedures were more likely to be highly detailed (all P < 0.05). Compared to poorly detailed operative reports, cases with highly detailed reports had fewer SSIs (13.2% vs 7.5%, P = 0.006), hernia recurrence (65.8% vs 55.4%, P = 0.002), and reoperation (78.9% vs 62.6%, P = 0.001).

Conclusions

In this medico-legal dataset, most VHR operative reports are poorly detailed while highly detailed operative reports were associated with lower rates of complications. Future studies should examine a nationally representative dataset to validate our findings.

The utility of synoptic operation reports in colorectal surgery: a systematic review

PURPOSE

Accurate documentation is crucial in surgical patient care. Synoptic reports (SR) are structured checklist-based reports that offer a standardised alternative to traditional narrative reports (NR). This systematic review aims to assess the completeness of SR compared to NR in colorectal cancer (CRC) surgery. Secondary outcomes include the time to completion, surgeon satisfaction, educational value, research value, and barriers to implementation.

METHODS

Prospective or retrospective studies that assessed SR compared to NR in colorectal cancer surgery procedures were identified through a systematic search of Ovid MEDLINE, Embase (Ovid), CIHNAL Plus with Full Text (EBSCOhost), and Cochrane. One thousand two articles were screened, and eight studies met the inclusion criteria after full-text review of 17 papers.

RESULTS

Analysis included 1797 operative reports (NR, 729; SR, 1068). Across studies reporting this outcome, the completeness of documentation was significantly higher in SR (P < 0.001). Reporting of secondary outcomes was limited, with a predominant focus on research value. Several studies demonstrated significantly reduced data extraction times when utilising SR. Surgeon satisfaction with SR was high, and these reports were seen as valuable tools for research and education. Barriers to implementation included integrating SR into existing electronic medical records (EMR) and surgeon concerns regarding increased administrative burden.

CONCLUSIONS

SR offer advantages in completeness, data extraction, and communication compared to NR. Surgeons perceive them as beneficial for research, quality improvement, and teaching. This review supports the necessity for development of user-friendly SR that seamlessly integrate into pre-existing EMRs, optimising patient care and enhancing the quality of CRC surgical documentation.

Enhancing operative documentation of emergency laparotomy: a systematic review and development of a synoptic reporting template

INTRODUCTION

Currently, operative reports are narrative and often handwritten, making interpretation difficult and potentially omitting key steps of the procedure. This study undertook a systematic review to determine the current availability of synoptic operative reporting and develop a synoptic operative record template for emergency laparotomy (EL).

METHODS

A PROSPERO registered study from January 1st, 2012, to December 31st, 2022, was conducted using PubMed, Scopus, and Web of Science databases in February 2023.

KEYWORDS

emergency laparotomy AND operation notes OR operative notes OR documentation OR report OR pro forma OR narrative OR synoptic OR digital OR audio-visual. Studies on paediatric or pregnant patients, systematic reviews, meta-analyses, case reports, editorial comments, and letters were excluded. A synoptic operative record was designed to include key standards in the documentation, as suggested by the Colleges of Surgeons.

RESULTS

The literature search yielded 4687 articles, and no relevant published articles were found. A detailed synoptic template was developed, which included 111 fields related to patient demographics, operative findings, interventions, and documentation of key variables associated with patient outcomes. 11 were text boxes, two were related to digital audio-visual uploads, and three facilitated the digital scoring/grading of findings.

CONCLUSION

This systematic review identified a limited number of publications reporting synoptic operative reporting, and none related to emergency laparotomy. This novel operative template provides a platform for clear documentation of the surgery performed during emergency laparotomy, potentially facilitating data analysis, resident training, and research, in turn leading to a better understanding of patient outcomes.

Development of a template for operative reporting of pediatric cancer surgery in limited-resource settings by using a modified Delphi method

PURPOSE

A comprehensive operative report for cancer surgery is crucial for accurate disease staging, risk stratification, and therapy escalation/de-escalation, which affects the outcome. Narrative operative reports may fail to include some critical findings. Furthermore, standardized operative reports can form the basis of a local registry, which is often lacking in limited-resource settings (LRSs). In adult literature, synoptic operative reports (SOR) contain more key findings than narrative operative reports. In the LRSs, where the capacity of diagnostic pathology services is typically suboptimal, the value of a thorough operative report is even greater. The aim of this study was to develop a SOR template to help standardize childhood cancer surgery reporting in LRSs.

METHODS

Twenty-three experts in pediatric cancer with extensive experience practicing in LRSs were invited to participate in a modified Delphi procedure. SOR domains for pediatric oncology surgery were drafted based on a literature search and then modified based on experts' opinions. The experts anonymously answered multiple rounds of online questionnaires until all domains and subdomains reached a consensus, which was predefined as 70% agreement.

RESULTS

Sixteen experts participated in the study, and two rounds of the survey were completed. Twenty-one domains were considered relevant, including demographics, diagnosis, primary site, preoperative disease stage, previous tumor biopsy or surgery, preoperative tumor rupture, neoadjuvant therapy, surgical access, type of resection, completeness of resection, tumor margin assessment, locoregional tumor extension, organ resection, intraoperative tumor spillage, vascular involvement, lymph node sampling, estimated blood loss, intraoperative complications and interventions to address them, specimen names, and specimen orientation.

CONCLUSION

We developed a SOR template for pediatric oncology surgery in LRSs. Consensus for all 21 domains and associated subdomains was achieved using a modified Delphi procedure.

Operative dictations in surgical trainees: an underutilized educational resource?

INTRODUCTION

Accurate operative notes are imperative to patient care and are used for communication, billing, quality assurance, and medical-legal conflicts. However, operative note quality often varies and many lack critical details. Unfortunately, no standardized training exists in operative dictations for surgical trainees. This pilot study sought to determine resident ability to dictate a comprehensive operative note and to determine a need for a formal operative dictation curriculum.

METHODS

Thirty-eight surgical residents between post-graduate years (PGY) one to four participated in a ventral hernia repair simulation. One senior (PGY3/4) resident coached two junior residents (PGY1/2). Residents completed an informal needs assessment regarding operative dictations. Post-simulation, residents completed an operative dictation. Notes were graded using a modified validated rubric.

RESULTS

Thirty-five residents completed the needs assessment, and 38 residents submitted an operative note. Eighty-two percent of this group have completed ≤ 25 operative dictations in training and 77% have received minimal feedback on operative dictations. Out of 33 total points, mean overall score was 18.9 ± 5.4 (Junior resident: 17.9 ± 5.4; Senior resident: 20.9 ± 4.8) Total mean scores did not significantly differ between junior and senior residents (p = 0.10). Senior and junior residents scored similarly on the procedural details component (p = 0.29). Senior residents scored higher on relevant patient history and operative note headers (p = 0.04).

CONCLUSION

Standard surgical training may not provide enough teaching and feedback to residents on operative note dictations. A formal residency training curriculum may bolster trainee ability to learn the components of an effective operative note.

Comparison of surgeon and pathologist total mesorectal excision grade after rectal cancer resection: A single institution analysis

BACKGROUND

A Michigan Surgical Quality Collaborative Colorectal Cancer Project initiative sought to increase adoption of surgeon total mesorectal excision (TME) grading through standardized education and synoptic operative reporting. Our study aim was to assess initiative impact and level of agreement between surgeon and pathologist-determined TME grades.

METHODS

This is a retrospective comparison of surgeon and pathologist TME grades before and after initiative implementation using a prospectively maintained enhanced recovery colorectal surgery database.

RESULTS

There were 112 TMEs before, and 53 TMEs following initiative implementation. There was a significant increase in surgeon TME-grade reporting in the postinitiative period (25.0% pre- vs. 81.1% post-, p < 0.001). Pathologist TME-grade reporting was high in both time periods and there was no significant change (91.1% pre- vs. 88.7% post-, p = 0.84). Surgeon and pathologist agreement was 59.3% in the preinitiative period (Κ "minimal"   0.356) and 65.0% in the postinitiative period (Κ "moderate" = 0.605, p = 0.827). There was no significant association between clinical T-stage and surgeon or pathologist TME grade.

CONCLUSION

Surgeon TME grading improves with education and synoptic operative reporting. There is only moderate agreement between surgeon and pathologist, a finding that requires further study. Organized regional initiatives are effective at implementing rectal cancer management quality improvement.

Improving operative documentation in colorectal cancer surgery: synoptic notes pave the way forward

BACKGROUND

Synoptic operative reports may improve reporting of key operative information. This study aimed to compare information included in synoptic reports with narrative notes following the introduction of a synoptic reporting system at a tertiary colorectal cancer referral centre.

METHODS

A standardized synoptic template incorporating the operative fields in the Australasian Bi-National Colorectal Cancer Audit (BCCA) was introduced for colorectal cancer surgery at the host institution in 2017. Colorectal cancer patients were identified from a prospectively collected database to collate samples of synoptic and narrative operative reports for comparison. The primary outcome was reporting of colon and rectal cancer-specific quality measures. Synoptic reporting of quality measures by clinician grade and uptake of synoptic reporting were also measured.

RESULTS

Five hundred and ninety-five operative reports were reviewed; 84% of all quality measures were included in synoptic reports and 43% in narrative reports describing colon cancer surgery (P <0.001). Synoptic reports describing rectal cancer surgery included 84% of quality measures with 40% reported in narrative reports (P <0.001). Reporting for most individual quality measures did not change depending on clinician experience. Synoptic reporting methods were used to document 80% of all colon cancer surgery and 84% of rectal cancer surgery.

CONCLUSION

Synoptic operative reports were superior to narrative reports in documenting quality measures. Synoptic reporting facilitates simultaneous data capture and bulk upload for audits including the BCCA. Development of synoptic operative reports standardized across Australasian colorectal cancer centres should be further investigated as a tool to facilitate collaborative audit and research.

New Operative Reporting Standards: Where We Stand Now and Opportunities for Innovation

BACKGROUND

The American College of Surgeons Commission on Cancer's (CoC) new operative standards for breast cancer, melanoma, and colon cancer surgeries will require that surgeons provide synoptic documentation of essential oncologic elements within operative reports. Prior to designing and implementing an electronic tool to support synoptic reporting, we evaluated current documentation practices at our institution to understand baseline concordance with these standards.

METHODS

Applicable procedures performed between 1 January 2018 and 31 December 2018 were included. Two independent reviewers evaluated sequential operative notes, up to a total of 100 notes, for documentation of required elements. Complete concordance (CC) was defined as explicit documentation of all required CoC elements. Mean percentage CC and surgeon-specific CC were calculated for each procedure. Interrater reliability was assessed via Cohen's kappa statistic.

RESULTS

For sentinel lymph node biopsy, mean CC was 66% (n = 100), with surgeon-specific CC ranging from 6 to 100%, and for axillary dissection, mean CC was 12% (n = 89) and surgeon-specific CC ranged from 0 to 47%. The single surgeon performing melanoma wide local excision had a mean CC of 98% (n = 100). For colon resections, mean CC was 69% (n = 96) and surgeon-specific CC ranged from 39 to 94%. Kappa scores were 0.77, 0.78, -0.15, and 0.78, respectively.

CONCLUSIONS

We identified heterogeneity in current documentation practices. In our cohort, rates of baseline concordance varied across surgeons and procedures. Currently, documentation elements are interspersed within the operative report, posing challenges to chart abstraction with resulting imperfect interrater reliability. This presents an exciting opportunity to innovate and improve compliance by introducing an electronic synoptic documentation tool.

Structured CT reporting of pancreatic ductal adenocarcinoma: impact on completeness of information and interdisciplinary communication for surgical planning

PURPOSE

With the rise in popularity of structured reports in radiology, we sought to evaluate whether free-text CT reports on pancreatic ductal adenocarcinoma (PDAC) staging at our institute met published guidelines and assess feedback of pancreatic surgeons comparing free-text and structured report styles with the same information content.

METHODS

We retrospectively evaluated 298 free-text preoperative CT reports from 2015 to 2017 for the inclusion of key tumor descriptors. Two surgeons independently evaluated 50 free-text reports followed by evaluation of the same reports in a structured format using a 7-question survey to assess the usefulness and ease of information extraction. Fisher's exact test and Chi-square test for independence were utilized for categorical responses and an independent samples t test for comparing mean ratings of report quality as rated on a 5-point Likert scale.

RESULTS

The most commonly included descriptors in free-text reports were tumor location (99%), liver lesions (97%), and suspicious lymph nodes (97%). The most commonly excluded descriptors were variant arterial anatomy and peritoneal/omental nodularity, which were present in only 23% and 42% of the reports, respectively. For vascular involvement, a mention of the presence or absence of perivascular disease with the main portal vein was most commonly included (87%). Both surgeons' rating of overall report quality was significantly higher for structured reports (p < 0.001).

CONCLUSION

Our results indicate that free-text reports may not include key descriptors for staging PDAC. Surgeons rated structured reports that presented the same information as free-text reports but in a template format superior for guiding clinical management, convenience of use, and overall report quality.

Is synoptic operative reporting necessary for Crohn's disease surgery? Variability in surgical reports across inflammatory bowel disease referral centres

AIM

Ileocolic resection (ICR) is the most commonly performed operation in Crohn's disease (CD) patients. The surgical report is a vital tool for accessing information to gauge a patient's long-term prognosis and guide treatment decisions. Dictated narrative reports are the traditional method for surgical documentation but often lack essential information. The objective was to assess the quality of operation note in CD patients undergoing ICR.

METHOD

This was a multi-institutional retrospective cohort collaborative study involving four tertiary inflammatory bowel disease referral centres in the USA and Canada. The patients were consecutive CD patients undergoing ICR between 2014 and 2020. There were no interventions. The main outcome measures were the variability and frequency of 28 critical items in the operation note.

RESULTS

An analysis of 400 consecutive operation reports in four institutions (n = 100/institution) revealed significant variability in almost all variables. The initial surgical approach and wound protector use were the most consistently or frequently reported across all inflammatory bowel disease centres. The limitation was that this was a retrospective cohort study with inevitable selection bias.

CONCLUSIONS

This study highlights the need for synoptic reporting in CD patients undergoing ICR.

Implementation of a synoptic operative note for abdominal wall hernia repair: a statewide pilot evaluating completeness and communication of intraoperative details

Background

Variable approaches to intraoperative communication impede our understanding of surgical decision-making and best practices. This is critical among hernia repairs, where improved outcomes are reliant on understanding the impact of different patient characteristics and surgical approaches. In this context, a hernia-specific synoptic operative note was piloted as part of an effort to create a statewide hernia registry. We aimed to understand the impact of the synoptic operative note on variable missingness and evaluate barriers and facilitators to improved intraoperative communication and note adoption.

Methods

In January 2020, the Michigan Surgical Quality Collaborative (MSQC) registry was expanded to capture hernia-specific intraoperative variables. A synoptic operative note for hernia repair was piloted at 8 hospitals. The primary outcome was change in hernia variable communication, measured by missingness. Using a sequential explanatory mixed-methods design, we performed semi-structured interviews with data abstractors (n = 4) and surgeons (n = 4) at 5 pilot sites to assess barriers and facilitators of implementation. Interviews were iteratively analyzed using content analysis with both deductive and inductive approaches.

Results

From January to June 2020, 870 hernia repairs were performed across 8 pilot and 53 control sites. Pilot sites had significantly less missingness for all hernia-specific variables. At pilot sites, 46% of notes were fully complete in regard to hernia variables, compared to 21% at control sites (p value < 0.001). While collection of intraoperative variables improved after synoptic note implementation, low note adoption was reported. Facilitators of improved variable collection were (1) communication with data abstractors and (2) stakeholder acknowledgment of widespread benefit, while barriers included (1) surgeon resistance to practice change, (2) EMR/technology, and (3) interruptions to communication and implementation.

Conclusion

This mixed-methods evaluation of a synoptic operative note implementation suggests that sustained communication, particularly with abstractors, was the most impactful intervention. Future implementation efforts may have improved effectiveness with interventions supplementary to surgeon-level direction.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08614-8.

Degree of biliary tract violation during treatment of gallbladder adenocarcinoma is independently associated with development of peritoneal carcinomatosis

BACKGROUND

Gallbladder cancer (GBC) is often incidentally diagnosed after cholecystectomy. Intra-operative biliary tract violations (BTV) have been recently associated with development of peritoneal disease (PD). The degree of BTV may be associated with PD risk, but has not been previously investigated.

METHODS

We reviewed patients with initially non-metastatic GBC treated at our institution from 2003 to 2018. Patients were grouped based on degree of BTV during their treatment: major (e.g., cholecystotomy with bile spillage, n = 27, 29%), minor (e.g., intra-operative cholangiogram, n = 18, 19%), and no violations (n = 48, 55%). Overall survival (OS) and peritoneal disease-free survival (PDFS) were evaluated with Kaplan-Meier and Cox proportional hazards modeling.

RESULTS

Ninety-three patients were identified; the median age was 64 years (range 31-87 years). Seventy-six (82%) were incidentally diagnosed. The median follow-up was 23 months; 20 (22%) patients developed PD. The 3-year PDFS for patients with major, minor, and no BTV was 52%, 83%, and 98%, respectively (major vs. none: p <  0.001; minor vs. none: p <  0.01). BTV was not associated with 5-year OS (HR 1.53, p =  0.16).

CONCLUSION

Increasing degree of BTV is associated with higher risk of peritoneal carcinomatosis in patients with GBC and should be considered during preoperative risk stratification. Reporting biliary tract violations during cholecystectomy is encouraged.

Case costing in spine surgery: Can surgeons assist with accurate capture of operating room costs?

Surgical case costing is critical for health leaders to make decisions about resource utilization. Synoptic reporting offers the potential for surgeons to capture these costs and work with other leaders to make evidence-based decisions. The purpose of this study was to determine whether surgeons documented intra-operative cost drivers as part of their operative report. This article outlines a synoptic reporting system at a quaternary spine care centre. Data were captured from 2015 to 2020. Surgeon rates of documentation for specific devices, bone graft, and surgical adjuncts were evaluated. It is hoped that the results of this survey will help to guide programs to capture costs in other settings.