The impact of gender, race, and ethnicity on bariatric surgery outcomes

BACKGROUND

The rates of postoperative complications can vary among specific patient populations.

OBJECTIVES

The aim of this study is to examine how gender, race, and ethnicity can affect short-term postoperative complications in bariatric surgery patients.

SETTING

United States.

METHODS

Patients who underwent bariatric surgery between the years 2016 and 2021 were included and stratified based on gender, race/ethnicity, and procedure type. The 30-day outcomes were assessed using Clavien-Dindo (CD) classification of III-V. Wilcoxon rank-sum test was performed to compare continuous variables among groups and Chi-squared test for categorical variables. Logistic regression was performed to examine the effects of gender, race/ethnicity on CD classification ≥ III complications by the procedure type.

RESULTS

A total of 975,642 bariatric surgery patients were included. Descriptive univariate analysis showed that CD ≥ III complications were higher among non-Hispanic blacks (NHB) and lowest in Hispanic patients, regardless of their gender, except in the duodenal switch DS group, where non-Hispanic whites (NHW) had the lowest complication rate. There was no difference between male and female patients with regards to postoperative complications, except in the sleeve gastrectomy (SG) group, where NHW males had more complications than NHW females. Sleeve gastrectomy showed the lowest complication rates followed by gastric bypass and DS in all groups. In multivariate logistic regression model, for both females and males NHBs had higher odds of postoperative complications compared to NHWs in sleeve gastrectomy (Female aOR:1.31, 95% CI: [1.23-1.40]; Male aOR:1.24, 95% CI: [1.08-1.43], P < .001) and gastric bypass (Female aOR:1.24, 95% CI: [1.16-1.33]; Male aOR:1.25, 95% CI: [1.06-1.48], P < .01).

CONCLUSIONS

Non-Hispanic Black patients are at a higher rate of developing CD ≥ III complications compared to non-Hispanic Whites after bariatric surgery. The male gender was not a significant risk factor for serious postoperative complications. Among the different types of bariatric procedures, sleeve gastrectomy has the lowest rates of severe complications, followed by gastric bypass and duodenal switch. These results highlight the significance of considering gender, race, ethnicity, and procedure type during preoperative evaluation, surgical planning, and postoperative care.

First Assistant In Bariatric Surgery: A Comparison Between Laparoscopic And Robotic Approaches: A 4-Year Analysis of the MBSAQIP Database (2016-2019)

PURPOSE

The first assistant (FA) plays an important role in the operating room for bariatric surgery. The aim of this study was to examine the relationship between the type of FA and operative time (OT) and postoperative outcomes comparing robotic and laparoscopic approaches in bariatric surgery.

METHODS AND MATERIALS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data for 2016-2019 was queried. Log-normal regression was performed to evaluate the association of FAs and OT variations within and between groups. We used logistic regression to examine the relationship between the type of FA and 30-day outcomes across all procedures and approaches.

RESULTS

A total of 691,789 patients who underwent robotic (R), and laparoscopic (L) sleeve gastrectomy (SG), Roux-en-Y gastric-bypass (RYGB), and duodenal switch (DS) were included. The percentage variation of OT was higher in the laparoscopic group (L-SG: 8.18%, L-RYGB: 9.88%, and L-DS: 15.00%) compared to the robotic group (R-SG: 2.43%, R-RYGB: 5.76%, and R-DS: 0.80%). There was not a significant difference in 30-day outcomes between laparoscopic and robotic approaches for the same procedures.

CONCLUSIONS

The FA was associated with a decreased variability in OT in the robotic cohort compared to the laparoscopic group with no significant difference in complication rates. These results suggest that the robotic approach may decrease the need for skilled FAs in bariatric procedures.

Dolichocolon (redundant colon) in a rhesus macaque (Macaca mulatta)

Dolichocolon (redundant colon) is an underdiagnosed cause of severe constipation in humans. The clinical presentation reported here in a rhesus macaque closely resembles that of intestinal adenocarcinoma, the most common neoplasia in macaques. Dolichocolon should be considered in differential diagnosis of macaques with anorexia, weight loss, and constipation.

Additive manufacture of PLLA scaffolds reinforced with graphene oxide nano-particles via digital light processing (DLP)

In this study, 3D printing of poly-l-lactic acid (PLLA) scaffolds reinforced with graphene oxide (GO) nanoparticles via Digital Light Processing (DLP) was investigated to mimic bone tissue. Stereolithography is one of the most accurate additive manufacturing methods, but the dominant available materials used in this method are toxic. In this research, a biocompatible resin (PLLA) was synthetized and functionalized to serve the purpose. Due to the low mechanical properties of the printed product with the neat resin, graphene oxide nanoparticles in three levels (0.5, 1, and 1.5 wt%) were added with the aim of enhancing the mechanical properties. At first, the optimum post cure time of the neat resin was investigated. Consequently, all the parts were post-cured for 3 h after printing. Due to the temperature-dependent structure of GO, all samples were placed in an oven at 85°C for different time periods of 0, 6, 12, and 18 h to increase mechanical properties. The compression test of heat-treated samples reveals that the compressive strength of the printed parts containing 0.5,1, and 1.5% of GO increased by 151,162 ad 235%, respectively. Scaffolds with the designed pore sizes of 750 microns and a porosity of 40% were printed. Surface hydrophilicity test was performed for all samples showing that the hydrophilicity of the samples increased with increasing GO percentage. The degradation behavior of the samples was evaluated in a PBS environment, and it revealed that by increasing GO, the rate of component degradation increased, but the heat treatment had the opposite effect and decreased the degradation rate. Finally, besides improving biological properties, a significant increase in mechanical properties under compression can introduce the printed scaffolds as a suitable option for bone implants.

Gastric Cancer Surgery in the US: a Contemporary Trend Analysis of Lymphadenectomy and the Impact of Minimally Invasive Approaches

BACKGROUND

The National Comprehensive Cancer Network guidelines recommend harvesting 16 or more lymph nodes for the adequate staging of gastric adenocarcinoma. This study examines the rate of adequate lymphadenectomy over recent years, its predictors, and its impact on overall survival(OS).

STUDY DESIGN

The National Cancer Database was utilized to identify patients who underwent surgical treatment for gastric adenocarcinoma between 2006-2019. Trend analysis was performed for lymphadenectomy rates during the study period. Logistic regression, Kaplan-Meier survival plots, and Cox proportional hazard regression were utilized.

RESULTS

A total of 57,039 patients who underwent surgical treatment for gastric adenocarcinoma were identified. Only 50.5% of the patients underwent a lymphadenectomy of ≥ 16 nodes. Trend analysis showed that this rate significantly improved over the years, from 35.1% in 2006 to 63.3% in 2019 (p < .0001). The main independent predictors of adequate lymphadenectomy included high-volume facility with ≥ 31 gastrectomies/year (OR: 2.71; 95%CI:2.46-2.99), surgery between 2015-2019 (OR: 1.68; 95%CI: 1.60-1.75), and preoperative chemotherapy (OR:1.49; 95%CI:1.41-1.58). Patients with adequate lymphadenectomy had better OS than patients who did not: median survival: 59 versus 43 months (Log-Rank: p < .0001). Adequate lymphadenectomy was independently associated with improved OS (HR:0.79; 95%CI:0.77-0.81). Laparoscopic and robotic gastrectomies were independently associated with adequate lymphadenectomy compared to open, OR: 1.11, 95%CI:1.05-1.18 and OR: 1.24, 95%CI:1.13-1.35, respectively.

CONCLUSION

Although the rate of adequate lymphadenectomy improved over the study period, a large number of patients still lacked adequate lymph node dissection, negatively impacting their OS despite multimodality therapy. Laparoscopic and robotic surgeries were associated with a significantly higher rate of lymphadenectomy ≥ 16 nodes.

Robotic Bariatric Surgery in Older Adults, Is It Safer Than the Laparoscopic Approach? A 7-Year Analysis of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database

BACKGROUND

Utilization of the robotic platform in bariatric surgery has increased over the past several years. The population of older adults who benefit from bariatric surgery is also growing. This study evaluated the safety of robotic-assisted bariatric surgery in older adults using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database.

METHODS

Adults who underwent gastric bypass or sleeve gastrectomy and were ≥ 65 years old between the years 2015 and 2021 were included. The 30-day outcomes were assessed and stratified based on Clavien-Dindo (CD) classification of III-V. Univariable and multivariable logistic regressions were performed to identify predictors of CD ≥ III complications.

RESULTS

A total of 62,973 bariatric surgery patients were included. Most of the patients (90%) underwent laparoscopic surgery, and the remainder (10%) underwent robotic surgery. Robotic sleeve gastrectomy (R-SG) was associated with lower odds of developing CD ≥ III complications compared to three other procedures (adjusted odds ratio (aOR), 0.741; confidence interval (CI), 0.584-0.941; p 0.014).

CONCLUSIONS

Bariatric surgery using a robotic approach is considered safe for older patients. Robotic sleeve gastrectomy (R-SG) has the lowest morbidity and mortality rates compared to laparoscopic sleeve gastrectomy (L-SG), laparoscopic Roux-en-Y gastric bypass (L-RYGB), and robotic Roux-en-Y gastric bypass (R-RYGB). The findings of this study can help surgeons and their elderly patients to make informed decisions regarding the safety of different bariatric surgical approaches.

A systematic review of robotic surgery curricula using a contemporary educational framework

BACKGROUND

There has been a rising trend in robotic surgery. Thus, there is demand for a robotic surgery curriculum (RSC) for training surgical trainees and practicing surgeons. There are limited data available about current curricular designs and the extent to which they have incorporated educational frameworks. Our aim was to study the existing robotic surgery curricula using Kern's 6-step approach in curriculum development.

METHODS

A systematic review was conducted using PubMed, PubMed Central, Cochrane, Embase, and Scopus (we searched studies from 2001 to 2021). PRISMA Guidelines was used to guide the search. Curriculum designed for general surgery and its subspecialties were included. Urology and gynecology were excluded. The articles were reviewed by five reviewers.

RESULTS

Our review yielded 71 articles, including 39 curricula at 9 different settings. Using Kern's framework, we demonstrated that the majority of robotic surgery curricula contained all the elements of Kern's curricular design. However, there were significant deficiencies in important aspects of these curricula i.e., implementation, the quality of assessment tools for measurement of performance and evaluation of the educational value of these interventions. Most institutions used commercial virtual reality simulators (VRS) as the main component of their RSC and 23% of curricula only used VRS.

CONCLUSIONS

Although majority of these studies contained all the elements of Kern's framework, there are critical deficiencies in the components of existing curricula. Future curricula should be designed using established educational frameworks to improve the quality of robotic surgery training.

Operative Time and 30-Day Outcomes in Bariatric Surgery: Comparison between Robotic and Laparoscopic Approach: 4-Year MBSAQIP Database Analysis

BACKGROUND

The main criticism of robotic surgery is longer operative time (OT). The aim of this study was to examine the variables that determine OT, the association between OT and 30-day outcomes, and the effect of the robotic approach in bariatric surgery.

STUDY DESIGN

MBSAQIP data for 2016 to 2019 were queried. Logistic regression was performed to examine the association between OT and outcomes for each surgical approach while adjusting for patients' characteristics. The results of each fitted logistic regression model were reported as odds ratio and the associated 95% CI.

RESULTS

A total of 666,182 patients underwent robotic sleeve gastrectomy (R-SG), laparoscopic sleeve gastrectomy, robotic Roux-en-Y gastric bypass (R-RYGB), laparoscopic Roux-en-Y gastric bypass, robotic duodenal switch (R-DS), and laparoscopic duodenal switch). More patients underwent laparoscopic surgery (89.7%) than robotic surgery (10.3%). OT for robotic cases was longer than for laparoscopic cases (p < 0.0001). Longer OT was associated with increased odds of adverse 30-day outcomes irrespective of the surgical approach. The association between OT and adverse outcomes was stronger in the laparoscopic cohort. There was no significant difference in postoperative outcomes when comparing the laparoscopic and robotic approaches after adjusting for OT, except a lower reoperation rate for R-SG (p = 0.03) and readmission rates in R-RYGB and R-DS (p < 0.01). The variability of OT was higher in the laparoscopic group and was more affected by the first assistant.

CONCLUSIONS

The outcomes in robotic bariatric surgery were comparable with the laparoscopic approach despite longer OT. Use of robotic surgery decreased the variability in OT.

The Impact of Navigation Grid Overlay on Performance of Camera Assistants during Laparoscopic Abdominal Procedures: A Randomized Controlled Trial

OBJECTIVE

Camera assistance is important for proper visualization of the operative field in laparoscopic surgery. Navigation grid (NG) has been designed to help the camera assistants focus the camera on the target operative field. This is a randomized, controlled trial to study the effect of the NG on performance of camera assistants.

DESIGN

Minimally invasive operations were randomized (1:1) to either with or without use of NG for the camera assistant. The operations were recorded and the time spent inside and outside of the target area were reported.

SETTING

A tertiary care teaching hospital.

RESULTS

Fifty-eight operations (30 with and 28 without NG) were recorded. Sixteen camera assistants participated. Time spent outside the target area was significantly less with the use of NG (64.5 ± 63 seconds vs 396 ± 226.5 seconds; p < 0.0001). This impact of NG on performance of the camera assistants was significant regardless of their level of training.

CONCLUSIONS

NG improved performance of the camera assistant during laparoscopic abdominal procedures. This is a feasible tool that can help camera holders better assist the operating surgeons.

Preparation for Challenging Cases: What Differentiates Expert From Novice Surgeons?

OBJECTIVE

The study of expert performance provides a rich field for exploration in the surgical literature. This study aimed to examine the difference between expert and novice surgeons in their preparation for challenging cases.

DESIGN

Expert (attending) and novice (postgraduate-year 2) surgeons were presented two cases of complicated cholecystitis and were asked how they would prepare, what they would expect to encounter intraoperatively, and how they would deal with these challenges. Their responses were recorded, transcribed verbatim and analyzed using thematic analysis.

SETTING

Academic teaching hospitals.

PARTICIPANTS

Two group of expert and novice surgeons.

RESULTS

Nine experts and eleven novices from two academic centers participated. The majority of novices focused on patient history, work-up, preoperative optimization, anatomy, and anticipation of intraoperative challenges. In addition to the patient's presentation and preoperative optimization, most experts' thoughts were directed toward preparation for surgery (level of urgency, required skills in surgical team, case difficulty, and risk of conversion to open). Experts would involve the patient in the decision-making and were more likely to communicate with the operating room team. While novices attempted to predict challenges depending on gallbladder condition and intra-abdominal adhesions, the experts highlighted the importance of various elements of the operative field, the detail of the technique and possible challenges, and their troubleshooting plans. Regarding operative planning to address anticipated challenges, novices would tailor their plan to patient characteristics and verbalized an analytical "if-then" approach for all possibilities they might encounter. Experts would start with their standard technique regardless of case complexity and would deal with contingencies as they arise. Safety was a critical part of expert surgeons' plans.

CONCLUSIONS

Novices mostly conveyed descriptive knowledge based on presented facts while experts demonstrated an ability to paint a richer mental image of possible future events by creating comprehensive anticipation of the operative field. Further studies are needed to validate the results of this study.

Practicing on the Advanced Training in Laparoscopic Suturing Curriculum (ATLAS): Is Mastery Learning in Residency Feasible to Achieve Expert-Level Performance in Laparoscopic Suturing?

BACKGROUND

Mastery learning assumes that given enough time and appropriate instructional strategies, most trainees will be able to achieve proficiency. Expert-level performance requires numerous hours of intensive and focus practice. We aimed to study whether it was possible for surgical trainees to achieve expert-derived proficiency level in laparoscopic suturing using the Advanced Training in Laparoscopic Suturing (ATLAS) curriculum over a short period of time.

STUDY DESIGN

A multicenter IRB approved prospective study included surgery residents and minimally invasive fellows. Participants underwent weekly supervised instruction and assessments of ATLAS skills and self-directed practice between sessions over 12 weeks. Participants were asked to practice until they achieved previously established proficiency benchmarks of expert laparoscopic surgeons.

RESULTS

Fifteen participants, PGY2 to PGY6, from 3 institutions practiced on the ATLAS curriculum. Three participants were able to achieve proficiency on the entire curriculum, with a cumulative practice time varying between 3.4 and 7.6 hours. Individual tasks had varying degrees of difficulty ranging from 85% proficiency on task 1 to 33.3% proficiency for task 6. Using a mixed-method model, the mean cumulative hours of practice to reach the benchmark threshold was estimated for each task and varied from 4.5 to 13.2 hours. The improved performance was associated with higher PGY level and proficiency in FLS.

CONCLUSIONS

This study demonstrates that it is possible for some senior surgical trainees to achieve proficiency in an expert-level laparoscopic suturing curriculum. This study establishes a learning curve for each ATLAS individual task. Some learners may not be able to achieve proficiency on the entire curriculum over a short period of practice. Additional studies are needed to assess how to shorten the learning curve with effective instructional methods such as expert-guided training with immediate feedback.

The impact of hemoglobin A1c on outcomes after lower extremity bypass

OBJECTIVE

Diabetes has been shown to be associated with increased risk of postoperative complications after lower extremity bypass (LEB), although it is unclear whether medium-term glucose control affects outcomes. This study aimed to assess the association of perioperative hemoglobin A_1c (HbA_1c) level on perioperative outcomes after LEB.

METHODS

We examined consecutive infrainguinal LEBs for chronic limb-threatening ischemia (CLTI) using the Vascular Quality Initiative database (2007-2018). Perioperative HbA_1c levels were stratified into <5.7%, 5.7% to 6.5%, and >6.5%. Propensity score matching on demographics, medical history, and procedural characteristics was used to select comparable patients across HbA_1c groups. The primary outcome was postoperative wound infection. Multivariable analyses were performed for matched and unmatched groups using Cox proportional hazards models for survival outcomes and logistic regression for binary outcomes with association expressed by adjusted hazard ratio (aHR) or adjusted odds ratio (aOR) and corresponding 95% confidence intervals (CIs).

RESULTS

The CLTI cohort included 8171 infrainguinal LEBs: 631 (7.7%) had HbA_1c <5.7%; 1691 (20.6%), 5.7% to 6.5%; and 5849 (71.6%), >6.5%. There was no difference in rates of wound infection in the CLTI cohort (HbA_1c ≤5.7%, 3.8%; HbA_1c 5.7%-6.5%, 3.7%; HbA_1c >6.5%, 3.2%; P = .53) or matched cohort (4.3%, 4.5%, 3.4%; P = .62). There were no differences in perioperative mortality in the CLTI cohort (2.5%, 1.7%, 1.5%; P = .16) or the matched cohort (2.7%, 2.3%, 2.2%; P = .84). In multivariable analysis, there was no significant association between HbA_1c and wound infection in the CLTI cohort (HbA_1c 5.7%-6.5% vs <5.7%: aOR, 0.91 [95% CI, 0.56-1.50; P = .72]; HbA_1c >6.5% vs <5.7%: aOR, 0.81 [95% CI, 0.52-1.26; P = .35]). There was, however, a significant association between decreased HbA_1c and mortality (HbA_1c 5.7%-6.5% vs <5.7%: aHR, 0.77 [95% CI, 0.61-0.97; P = .03]; HbA_1c >6.5% vs <5.7%: aHR, 0.75 [95% CI, 0.61-0.93; P = .01]).

CONCLUSIONS

Our study suggests no significant association of increased HbA_1c level and perioperative complications. Additional investigation is required to further evaluate the impact of short-term glycemic control and long-term outcomes of patients undergoing LEB.

Toward effective feedback: From concept to practice

Feedback is the building block of assessment and an essential component of effective teaching. In this article, we will provide a comprehensive definition of feedback and a relevant conceptual framework for learning to explain how feedback can be used to improve performance. We will discuss the process of providing feedback, and the role teacher and learner can play to make it more effective. We will also examine the misunderstandings and pitfalls around feedback, as well as generational differences that may influence its impact.

A frailty index and the impact of frailty on postoperative outcomes in older patients after bariatric surgery

BACKGROUND

The prognostic value of frailty in the elderly surgical population has been well studied across surgical specialties. However, no studies have yet explored the effects of frailty across the full spectrum of adverse events after bariatric surgery.

OBJECTIVES

To study the impact of index-frailty on the full range of adverse short-term outcomes after bariatric surgery.

METHODS

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data file for 2016 was used. Descriptive analyses, univariable, and multivariable regression models, assessed for discriminative and predictive capacities, were used to assess the effects of frailty on Clavien-Dindo categorized adverse outcomes within 30 days of bariatric surgery. Frailty index was modified from Canadian Study of Health and Aging Frailty Index.

SETTING

Data pooled from American Society for Bariatric Surgery-accredited bariatric surgery centers, United States.

RESULTS

A total of 21,426 patients aged ≥60 undergoing primary bariatric procedures were included. The prevalence of frailty as defined by the modified frailty index was 44.4%. Frail status was independently associated with higher odds of 30-day adverse events (Clavien-Dindo grades I, II, III, IV, and V). Frailty scores had weakly positive correlations with increasing age and increasing body mass index in the bariatric patients.

CONCLUSION

Frailty can be used as a risk stratification modality for patients before bariatric surgery. Further research should focus on exploring the relationship between obesity and frailty and the effects of weight loss on frailty status of bariatric patients.

Development of a bariatric surgery specific risk assessment tool for perioperative myocardial infarction

BACKGROUND

Perioperative myocardial infarction (PMI) is a feared complication after surgery. Bariatric surgery, due to its intraabdominal nature, is traditionally considered an intermediate risk procedure. However, there are limited data on MI rates and its predictors in patients undergoing bariatric surgery.

OBJECTIVES

To enumerate the prevalence of PMI after bariatric surgery and develop a risk assessment tool.

SETTING

Bariatric surgery centers, United States.

METHODS

Patients undergoing bariatric surgery were identified from the MBSAQIP participant use file (PUF) 2016. Preoperative characteristics, which correlated with PMI were identified by multivariable regression analysis. PUF 2015 was used to validate the scoring tool developed from PUF 2016.

RESULTS

We identified 172,017 patients from PUF 2016. Event rate for MI within 30 days of the operation was .03%; with a mortality rate of 17.3% in patients with a PMI. Four variables correlated with PMI on regression, including history of a previous MI (odds ratio [OR] = 8.57, confidence interval [CI] = 3.4-21.0), preoperative renal insufficiency (OR = 3.83, CI = 1.2-11.4), hyperlipidemia (OR = 2.60, CI = 1.3-5.1), and age >50 (OR = 2.15, CI = 1.1-4.2). Each predicting variable was assigned a score and event rate for MI was assessed with increasing risk score in PUF 2015; the rate increased from 9.5 per 100,000 operations with a score of 0 to 3.2 per 100 with a score of 5.

CONCLUSION

The prevalence of MI after bariatric surgery is lower than other intraabdominal surgeries. However, mortality with PMI is high. This scoring tool can be used by bariatric surgeons to identify patients who will benefit from focused perioperative cardiac workup.

Surgeons' expertise during critical event in laparoscopic cholecystectomy: An expert-novice comparison using protocol analysis

BACKGROUND

The purpose of this study was to examine differences in thought processes between novice and experienced surgeons when they were presented with a critical situation during laparoscopic cholecystectomy.

METHODS

A group of experienced and novice surgeons were shown a recording of a laparoscopic cholecystectomy with an intraoperative bleeding event. The think-aloud method was used to capture surgeons' thought processes. Verbal reports were recorded, transcribed and analyzed using the protocol analysis method.

RESULTS

Sixteen subjects (8 in each group) participated at two centers. Experienced surgeons demonstrated deeper comprehension of the operative field, richer mental image of future events and superior awareness of potentially dangerous situations. They also spent more time engaged in metacognitive activity.

CONCLUSIONS

This study highlights the differences and similarities between surgeons with different levels of experience during a challenging intraoperative encounter. The domains of cognition and mental image as well as metacognition appear to be key elements of surgical expertise.

Robotic-Assisted Simultaneous Repair of Paraesophageal Hernia and Morgagni Hernia: Technical Report

Morgagni hernias are a rare form of congenital diaphragmatic hernia, accounting for 2%-3% of cases. The presence of a simultaneous Morgagni hernia and paraesophageal hernia (PEH) is even more rare, with only a few reported cases in the surgical literature. Both open and laparoscopic surgical approaches have been previously described. Herein we discuss a robotic-assisted surgical approach to the repair of simultaneous Morgagni hernia and PEH in a 65-year-old woman. Simultaneous repair of Morgagni hernia and PEH is indicated mainly when symptoms are generally indistinctive. The use of robotic technology allowed for both hernias to be repaired both primarily and with mesh reinforcement.

Robotic-Assisted Paraesophageal Hernia Repair: Initial Experience at a Single Institution

BACKGROUND

Laparoscopic surgery is considered the standard approach for the treatment of paraesophageal hernias (PEHs). Despite its advantages, this approach is technically demanding with a significant learning curve. Data about the safety and utility of the robotically assisted paraesophageal hernia repair (RA-PEHR) are scarce. The aim of this study is to assess the feasibility and safety of robotic assistance for the treatment of PEH.

MATERIALS AND METHODS

Between June 2010 and December 2015, patients who underwent elective RA-PEHR were included in a prospectively collected database. Demographic data, American Society of Anesthesiologists (ASA) classification, preoperative testing, operative time (OT), length of hospital stay (LOS), conversion rate, morbidity, and mortality were recorded and reviewed retrospectively.

RESULTS

Sixty-one patients underwent RA-PEHR with mesh, 72% were female (mean age of 63 and mean body mass index [BMI] of 30). ASA classification was 2.6 (57% of patients had an ASA III). With respect to the type of the hernia, the preoperative diagnosis was: Type II 26%, III 64%, and IV 13%. OT averaged 186 minutes (88-360), including robot setup time. After the 16th case, OT significantly decreased by 4.09 minutes (P = .01). There were no conversions. The average blood loss was 51 mL. Perioperative complications, including intraoperative and 30-day complications, were 6% and 23%, respectively. The mean length of hospitalization was 2.6 (1-18) days. There were no deaths. Forty patients (66%) were available for follow-up, and length of follow-up was 17 ± 15 months. Anatomic recurrence was observed in 42% of patients and only 23% of patients were symptomatic.

CONCLUSIONS

This report represents the largest series to date of RA-PEHR. RA-PEHR has proved to be feasible and safe with a learning curve comparable to the standard laparoscopic approach.

Reduced Survival in Bariatric Surgery Candidates Delayed or Denied by Lack of Insurance Approval

Bariatric surgery reduces mortality for Americans who meet candidacy criteria and have insurance coverage. Unfortunately, some medically suitable candidates are denied or delayed during insurance approval processes. The long-term impact of such care delays on survival is unknown. Using a prospectively maintained bariatric intake database, we identified consecutive applicants who were evaluated and medically cleared by our multidisciplinary care team and for whom insurance approval was requested. We compared survival in those who were initially approved by their insurance carriers (controls) and those who were initially denied coverage (subjects). Mortality was determined using the Social Security Death Index. Kaplan–Meier survival curves were plotted and the log-rank test for significance was applied. From August 2003 to December 2008, 463 patients (391 females, mean age 45 ± 10 years, mean body mass index 52.5 ± 9.4 kg/m2) were medically cleared for a bariatric procedure. Of these, 363 were approved by insurance on initial request, whereas 100 were denied. Given the study's intention to measure the aggregate impact of delays and denials, nine patients who later came to operation after appeal or coverage change were maintained in the subject cohort. During 0- to 113-month follow-up, six subjects (6%) died compared with seven controls (1.9%), corresponding to a statistically significant survival benefit for patients initially approved for bariatric surgery without delay or denial ( P < 0.001). In conclusion, access to bariatric surgical care was impeded by insurance certification processes in 22 per cent of medically acceptable candidates. Processes that delay or restrict efficient access to bariatric surgery are associated with a 3-fold mortality increase.

Reduced Survival in Bariatric Surgery Candidates Delayed or Denied by Lack of Insurance Approval

Bariatric surgery reduces mortality for Americans who meet candidacy criteria and have insurance coverage. Unfortunately, some medically suitable candidates are denied or delayed during insurance approval processes. The long-term impact of such care delays on survival is unknown. Using a prospectively maintained bariatric intake database, we identified consecutive applicants who were evaluated and medically cleared by our multidisciplinary care team and for whom insurance approval was requested. We compared survival in those who were initially approved by their insurance carriers (controls) and those who were initially denied coverage (subjects). Mortality was determined using the Social Security Death Index. Kaplan-Meier survival curves were plotted and the log-rank test for significance was applied. From August 2003 to December 2008, 463 patients (391 females, mean age 45 ± 10 years, mean body mass index 52.5 ± 9.4 kg/m(2)) were medically cleared for a bariatric procedure. Of these, 363 were approved by insurance on initial request, whereas 100 were denied. Given the study's intention to measure the aggregate impact of delays and denials, nine patients who later came to operation after appeal or coverage change were maintained in the subject cohort. During 0- to 113-month follow-up, six subjects (6%) died compared with seven controls (1.9%), corresponding to a statistically significant survival benefit for patients initially approved for bariatric surgery without delay or denial (P < 0.001). In conclusion, access to bariatric surgical care was impeded by insurance certification processes in 22 per cent of medically acceptable candidates. Processes that delay or restrict efficient access to bariatric surgery are associated with a 3-fold mortality increase.

Measuring Patterns of Surgeon Confidence Using a Novel Assessment Tool

Confidence should increase during surgical training and practice. However, few data exist regarding confidence of surgeons across this continuum. Confidence may develop differently in clinical and personal domains, or may erode as specialization or age restricts practice. A reliable scale of confidence is needed to track this competency. A novel survey was distributed to surgeons in private and academic settings. One hundred and thirty-four respondents completed this cross-sectional survey. Surgeons reported anticipated reactions to clinical scenarios within three patient care domains (acute inpatient, nonacute inpatient, and outpatient) and in personal spheres. Confidence scores were plotted against years of experience. Curves of best fit were generated and trends assessed. A subgroup completed a second survey after four years to assess the survey's reliability over time. During residency, there is steep improvement in confidence reported by surgeons in all clinical domains, with further increase for inpatient domains during transition into practice. Confidence in personal spheres also increases quickly during residency and thereafter. The surgeon confidence scale captures the expected acquisition of confidence during early surgical experience, and will have value in following trends in surgeon confidence as training and practice patterns change.

Measuring Patterns of Surgeon Confidence Using a Novel Assessment Tool

Confidence should increase during surgical training and practice. However, few data exist regarding confidence of surgeons across this continuum. Confidence may develop differently in clinical and personal domains, or may erode as specialization or age restricts practice. A reliable scale of confidence is needed to track this competency. A novel survey was distributed to surgeons in private and academic settings. One hundred and thirty-four respondents completed this cross-sectional survey. Surgeons reported anticipated reactions to clinical scenarios within three patient care domains (acute inpatient, nonacute inpatient, and outpatient) and in personal spheres. Confidence scores were plotted against years of experience. Curves of best fit were generated and trends assessed. A subgroup completed a second survey after four years to assess the survey's reliability over time. During residency, there is steep improvement in confidence reported by surgeons in all clinical domains, with further increase for inpatient domains during transition into practice. Confidence in personal spheres also increases quickly during residency and thereafter. The surgeon confidence scale captures the expected acquisition of confidence during early surgical experience, and will have value in following trends in surgeon confidence as training and practice patterns change.

GOALS-incisional hernia: a valid assessment of simulated laparoscopic incisional hernia repair

The Global Operative Assessment of Laparoscopic Skills (GOALS) is a valid and reliable measure of basic, non-procedure-specific laparoscopic skills. GOALS-incisional hernia (GOALS-IH) was developed to evaluate performance of laparoscopic incisional hernia repair (LIHR). The purpose of this study was to assess the validity and reliability of GOALS-IH during LIHR simulation. GOALS-IH assesses 7 domains with a maximum score of 35. A total of 12 experienced surgeons and 10 novices performed LIHR on the Surgical Abdominal Wall simulator. Performance was assessed by a trained observer and by self-assessment using GOALS-IH, basic GOALS and a visual analog scale (VAS) for overall competence. Both interrater reliability and internal consistency were high (.76 and .95 respectively). Experienced surgeons had higher mean GOALS-IH scores than novices (32.3 ± 2 versus 22.7 ± 5). There was excellent correlation between GOALS-IH and other measures of performance (GOALS r = .93 and VAS r = .93). GOALS-IH is easy to use, valid and reliable for assessment of simulated LIHR.

Surgical Abdominal Wall (SAW): a novel simulator for training in ventral hernia repair

Laparoscopic ventral hernia repair (LVHR) is a relatively common procedure that requires advanced minimally invasive surgical skills to perform. The role for simulation is increasingly supported as an effective way to teach surgical skills and accelerate the learning curve. This article describes The University of Maryland's Surgical Abdominal Wall, an inexpensive procedure-specific physical simulator for LVHR, and summarizes the authors' early experiences using this model in a curriculum for surgery residents.