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Leavitt J, Hager M, Edgerton C, Hooks WB, Hope W. Educating Residents in Abdominal Wall Closure: An Overview. J Abdom Wall Surg 2023; 2:12159. [PMID: 38312420 PMCID: PMC10831644 DOI: 10.3389/jaws.2023.12159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/22/2023] [Indexed: 02/06/2024]
Abstract
Background and Aims: Incisional hernia prevention has become an important concept for surgeons operating on the abdominal wall. Several techniques have been proposed to help decrease incisional hernia formation with suture closure of the abdominal wall being one of the cornerstones. Technical details that have been reported to decrease incisional hernia rates include achieving a 4:1 Suture to Wound length ratio and the use of a small bites technique. Despite evidence to support many of these techniques there appears to be a gap in practice patterns amongst practicing surgeons. Introducing and promoting these principles in surgical residency may help to close this gap. This paper reviews our experience with surgical training for abdominal wall closures at our institution. Materials and Methods: Programs and projects related to abdominal wall closure were reviewed from our institution from 2010-Present. Type of project, intervention, and impact on education was evaluated and summarized. Results: Seven projects were identified relating to surgical training and abdominal wall closure. Three projects dealt with skills training using an abdominal wall simulation model and related to suturing techniques. Two projects were clinical studies focused on suture to wound length ratios and improving outcomes with this variable in a residency training program. Two projects dealt with models relating to abdominal wall closure and education. Conclusion: Implementation of educational programs in surgical residency programs can lead to improvements in technique and knowledge around abdominal wall closure and help in research endeavors.
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Affiliation(s)
| | | | | | | | - William Hope
- Department of Surgery, Novant Health New Hanover Regional Medical Center, Wilmington, NC, United States
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Oyola AM, Miller J, Edgerton C, Hope W. Polymer versus Titanium Clips in Laparoscopic Cholecystectomy. Surg Technol Int 2023; 43:sti43/1730. [PMID: 37972547 DOI: 10.52198/23.sti.43.gs1730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
BACKGROUND Surgical clips are commonly used during laparoscopic cholecystectomy for cystic duct and artery ligation. Titanium and polymer clips are the two most common types used for this indication. Given the cost-saving potential, design advantages, and decreased incidence of complications associated with polymer clips, we sought to study whether there is a clinically significant difference in outcome between polymer and titanium clips in laparoscopic cholecystectomy. METHODS Fifty consecutive cases using polymer clips followed by 50 consecutive cases using metal clips over a 6-month period by residents under the direction of a single surgeon were retrospectively reviewed. The following outcomes were evaluated: incidence of bile leak, postoperative bleeding, need for additional procedures, hospital length of stay, and cost. RESULTS We found that significantly more misfires occurred with the use of the polymer clips (n=17) than with the titanium clips (n=2, p<.001). Eight cases (16%) required opening of an additional polymer clip cartridge to complete the operation. Despite this additional expense, the total cost as it pertained to clip usage ($30.32 USD) was still lower than that using titanium clips ($139.17 USD). While these numbers were not statistically significant, three cases had bile leaks and required additional procedures, all of which were performed with metal clips. No postoperative bleeds were identified and there was no difference in hospital length of stay; most patients were discharged on the day of the procedure. CONCLUSION These findings demonstrate comparable clinical outcomes between laparoscopic cholecystectomies performed with polymer and titanium clips, though polymer clip usage carries a lower cost.
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Affiliation(s)
- Anna Malysz Oyola
- Department of General Surgery Novant Health New Hanover Regional Medical Center Wilmington, NC
| | - John Miller
- Department of General Surgery Novant Health New Hanover Regional Medical Center Wilmington, NC
| | - Colston Edgerton
- Department of General Surgery Novant Health New Hanover Regional Medical Center Wilmington, NC
| | - William Hope
- Department of General Surgery Novant Health New Hanover Regional Medical Center Wilmington, NC
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Hager M, Edgerton C, Hope WW. Primary Uncomplicated Ventral Hernia Repair: Guidelines and Practice Patterns for Routine Hernia Repairs. Surg Clin North Am 2023; 103:901-915. [PMID: 37709395 DOI: 10.1016/j.suc.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Surgical repair of primary umbilical and epigastric hernias are among the most common abdominal operations in the world. The hernia defects range from small (<1 cm) to large and complex even in the absence of prior incision or repair. Mesh has generally been shown to decrease recurrence rates, and its use and location of placement should be individualized for each patient. Open, laparoscopic, and robotic approaches provide unique considerations for the technical aspects of primary repair with or without mesh augmentation.
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Affiliation(s)
- Matthew Hager
- Department of Surgery, Novant/New Hanover Regional Medical Center, 2131 South 17th Street, PO Box 9025, Wilmington, NC 28401, USA
| | - Colston Edgerton
- Department of Surgery, Novant/New Hanover Regional Medical Center, University of North Carolina - Chapel Hill, 2131 South 17th Street, PO Box 9025, Wilmington, NC 28401, USA
| | - William W Hope
- Department of Surgery, Novant/New Hanover Regional Medical Center, University of North Carolina - Chapel Hill, 2131 South 17th Street, PO Box 9025, Wilmington, NC 28401, USA.
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Cuevas N, Beeson ST, Faulkner JD, Edgerton C, Hope WW. Teaching Small Bite Fascial Closure Technique: Improved Accuracy and Consistency Through Simulation. Am Surg 2023:31348231160852. [PMID: 36935586 DOI: 10.1177/00031348231160852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Despite evidence that small bite closure is beneficial, it is not well documented how accurately and consistently surgeons employ this technique. We created a felt model to simulate fascial closure and educate residents regarding small bites. This study aims to gauge accuracy and consistency of bite size in fascial closure and assess if utilizing a templated model could improve technique. Two 10 cm incisions were made in different pieces of felt. Residents were instructed to suture the incisions to simulate fascial closure by running the incisions closed with 1 cm and 5 mm bites respectively. The process was repeated with templated pieces of felt marking 1 and 0.5 cm to guide bite size. Residents were timed for each closure. The travel and distance from the midline for each bite was measured and analysis performed. 14 residents participated. Paired T-test compared means and standard deviations of bite size. Taking 5 mm bites took more time. Standard deviation of travel and right sided distance from midline were significantly smaller when a template was utilized. Standard deviation of travel as well as right sided distance was also improved when instructed to take 5 mm bites. This study demonstrates that a small bite technique results more closure and that when residents are instructed to take smaller bites. The adage, "aim small, miss small," holds true in fascial closure and may be one reason why small bites improve hernia rates. This study also suggests that the use of a template improves accuracy and consistency of closure regardless of bite size intention.
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Affiliation(s)
| | - Seth T Beeson
- Department of Surgery, 24520Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
| | | | - Colston Edgerton
- Department of Surgery, 24520Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
| | - William W Hope
- 24520New Hanover Regional Medical Center, Wilmington, NC, USA
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Edgerton C, Heshmati K, Herman A, Dey T, Dehkharghani R, Ramsis R, Robinson M, Vernon A, Ghushe N, Spector D, Shikora S, Tavakkoli A, Sheu EG. Fellowship training influences learning curves for laparoscopic sleeve gastrectomy. Surg Endosc 2021; 36:1601-1608. [PMID: 33620566 DOI: 10.1007/s00464-021-08372-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 02/09/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgical procedure. Little is known about how surgeon training background influences the learning curve of this procedure. We examined operating times (OT), weight loss outcomes, and 30-day complications between surgeons with and without fellowship training in LSG. We hypothesize that post-residency training specific to LSG influences learning curves. METHODS Surgeons from a single institution were split into two groups: those who had not completed fellowship training in LSG (NF, n = 3), and those who had completed LSG specific training in fellowship (SGF, n = 3). OTs, BMI changes at 1 year, and 30-day readmissions, reoperations, and complications were extracted for the first 100 LSG cases of each surgeon. Data were analyzed in bins of 20 cases. Comparisons were made between cohorts within a bin and between adjacent bins of the same surgeon cohort. Logistic regression analyses were performed of OT and weight loss outcomes. RESULTS SGF surgeons showed no difference in OTs over their first 100 cases. NF surgeons had statistically significant increased OTs compared to SGF surgeons during their first 60 cases and progressively shortened OTs during that interval (109 min to 78 min, p < 0.001 for NF surgeons vs. 73 min to 69 min, SGF surgeons). NF surgeons had a significantly steeper slope for improvement in OT over case number. There was no correlation between case number and weight loss outcomes in either group, and no differences in 30-day outcomes between groups. CONCLUSION Surgeons who trained to perform LSG in fellowship demonstrate faster and consistent OR times on their initial independent LSG cases compared to surgeons who did not, with no correlation between case number and weight loss outcomes or safety profiles for either group. This suggests that learning curves for LSG are achieved during formal case-specific fellowship training.
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Affiliation(s)
- Colston Edgerton
- Division of Gastrointestinal Surgery, Center for Metabolic and Bariatric Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Keyvan Heshmati
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ashley Herman
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Tanujit Dey
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Robab Dehkharghani
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ramsis Ramsis
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Malcolm Robinson
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ashley Vernon
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Neil Ghushe
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - David Spector
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Scott Shikora
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Ali Tavakkoli
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.,Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Eric G Sheu
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA. .,Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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