Development and preliminary validation of a new task-based objective procedure-specific assessment of inguinal hernia repair procedural safety

BACKGROUND

Surgical videos coupled with structured assessments enable surgical training programs to provide independent competency evaluations and align with the American Board of Surgery's entrustable professional activities initiative. Existing assessment instruments for minimally invasive inguinal hernia repair (IHR) have limitations with regards to reliability, validity, and usability. A cross-sectional study of six surgeons using a novel objective, procedure-specific, 8-item competency assessment for minimally invasive inguinal hernia repair (IHR-OPSA) was performed to assess inter-rater reliability using a "safe" vs. "unsafe" scoring rubric.

METHODS

The IHR-OPSA was developed by three expert IHR surgeons, field tested with five IHR surgeons, and revised based upon feedback. The final instrument included: (1) incision/port placement; (2) dissection of peritoneal flap (TAPP) or dissection of peritoneal flap (TEP); (3) exposure; (4) reducing the sac; (5) full dissection of the myopectineal orifice; (6) mesh insertion; (7) mesh fixation; and (8) operation flow. The IHR-OPSA was applied by six expert IHR surgeons to 20 IHR surgical videos selected to include a spectrum of hernia procedures (15 laparoscopic, 5 robotic), anatomy (14 indirect, 5 direct, 1 femoral), and Global Case Difficulty (easy, average, hard). Inter-rater reliability was assessed against Gwet's AC2.

RESULTS

The IHR-OPSA inter-rater reliability was good to excellent, ranging from 0.65 to 0.97 across the eight items. Assessments of robotic procedures had higher reliability with near perfect agreement for 7 of 8 items. In general, assessments of easier cases had higher levels of agreement than harder cases.

CONCLUSIONS

A novel 8-item minimally invasive IHR assessment tool was developed and tested for inter-rater reliability using a "safe" vs. "unsafe" rating system with promising results. To promote instrument validity the IHR-OPSA was designed and evaluated within the context of intended use with iterative engagement with experts and testing of constructs against real-world operative videos.

RF03 | PMON302 A Unique Estrogen-Sensitive Fibroblast Population Drives Abdominal Muscle Fibrosis

 

Weakening of the lower abdominal wall muscle via fibrosis causes visceral contents to bulge out, forming inguinal hernias. Humanized aromatase (Aromhum) transgenic male mice develop this weakness in the lower abdominal muscle (LAM) tissue, characterized by extensive fibrosis, muscle atrophy, and scrotal hernias. This mouse model incorporates the human version of the aromatase gene allowing for excessive estradiol (E2) production in skeletal muscle tissue. We have previously shown that the LAM fibroblasts are sensitive to local E2 production due to high levels of estrogen receptor alpha (ERα, Esr1)¹. Here, we explore the origins of estrogen-driven muscle fibrosis in the LAM tissue of Aromhum mice at a single-cell level.

Wild-type (WT) and Aromhum LAM tissues were processed via single-cell RNA sequencing (n = 3) and analyzed using Seurat. We observed a total of 22 UMAP clusters, including six fibroblast-like clusters. Five of these clusters express the fibro-adipogenic progenitor (FAP) marker Pdgfrα, and two of them are exclusively found in Aromhum LAM tissues. One Aromhum-enriched cluster highly expresses Esr1 and its downstream estrogen-responsive genes such as Pgr and Greb1. Pseudo-time analysis suggested that this cluster differentiates into a pathogenic fibroblast cluster characterized by high expression pro-inflammatory (Il33, Il6, Ccl8, C4b) and fibrosis-associated (Mmp3, Cthrc1, Saa3, Ptx3) genes. We further validated our findings via flow cytometry, immunocytochemistry, and western blots in LAM, upper abdominal muscle tissues, and quadriceps of both WT and Aromhum mice. We show that protein levels of Pdgfrα, ERα, Mmp3, C4b are greater in the fibroblasts freshly isolated from LAM tissues of Aromhum mice compared to WT mice. Moreover, Aromhum LAM tissue cell cycle analysis reveals that ∼15% of all ERα+ cells are in the G2-S phase compared with <1% of ERα- cells. Overall, we provide an insight into the cell types, genes, and proteins that are dysregulated in the LAM tissues from Aromhum mice with hernias.

Inguinal hernias are found in ∼25% of the elderly male population². Using an inguinal hernia mouse model that mimics the hernia pathophysiology of elderly men with estrogen excess and testosterone deficiency, we defined a specific population of estrogen-sensitive fibroblasts responsible for fibrosis and weakening of lower abdominal skeletal muscle tissue associated with hernias. We provide an insight into the specific disease-causing fibroblast populations and molecular targets that may be the basis for future therapeutics to prevent or treat inguinal hernias.

References

1. Zhao H, Zhou L, Li L, et al. Shift from androgen to estrogen action causes abdominal muscle fibrosis, atrophy, and inguinal hernia in a transgenic male mouse model. Proceedings of the National Academy of Sciences. 2018;115(44): E10427-E10436.

2. Sazhin A, Zolotukhin I, Seliverstov E, et al. Prevalence and risk factors for abdominal wall hernia in the general Russian population. Hernia. 2019;23(6): 1237-1242.

Presentation: Saturday, June 11, 2022 1:06 p.m. - 1:11 p.m., Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Formative Evaluation of a Peer Video-Based Coaching Initiative

BACKGROUND

Few opportunities exist for surgeons to receive technical skills feedback after training. Surgeons at hospitals within the Illinois Surgical Quality Improvement Collaborative were invited to participate in a peer-to-peer video-based coaching initiative focused on improving technical skills in laparoscopic right colectomy. We present a formative qualitative evaluation of a video-based coaching initiative.

METHODS

Concurrent with the implementation of our video-based coaching initiative, we conducted two focus groups and 15 individual semistructured interviews with participants; all interviews were audio-recorded and transcribed. A subset of surgeons participated in a group video-review session, which was observed by qualitative researchers. Transcripts and notes were analyzed using an organizational behavior framework adapted from executive coaching.

RESULTS

Participation in the initiative was primarily motivated by the opportunity to learn from others and improve skills. Surgeons highlighted the value of self-video and peer-video assessment not only to learn new techniques but also for self-reflection and benchmarking. Barriers to participation included logistics (e.g. using the laparoscopic recording devices, coordinating schedules for peer coaching), time commitment, and a surgical culture that assumes the intent of coaching is to address deficiencies.

CONCLUSIONS

Video-based peer-coaching provides a platform for surgeons to reflect, benchmark against peers, and receive personalized feedback; however, more work is needed to increase participation and sustain involvement over time. There is an opportunity to decrease logistical barriers and increase acceptability of coaching by integrating video-based coaching into existing surgical conferences and established continuous professional development efforts.

Pricing of surgeries for colon cancer: patient severity and market factors

BACKGROUND

This study examined effects of health maintenance organization (HMO) penetration, hospital competition, and patient severity on the uptake of laparoscopic colectomy and its price relative to open surgery for colon cancer.

METHODS

The MarketScan Database (data from 2002-2007) was used to identify admissions for privately insured colorectal cancer patients undergoing laparoscopic or open partial colectomy (n = 1035 and n = 6389, respectively). Patient and health plan characteristics were retrieved from these data; HMO market penetration rates and an index of hospital market concentration, the Herfindahl-Hirschman index (HHI), were derived from national databases. Logistic and logarithmic regressions were used to examine the odds of having laparoscopic colectomy, effect of covariates on colectomy prices, and the differential price of laparoscopy.

RESULTS

Adoption of laparoscopy was highly sensitive to market forces, with a 10% increase in HMO penetration leading to a 10.9% increase in the likelihood of undergoing laparoscopic colectomy (adjusted odds ratio = 1.109; 95% confidence interval [CI] = 1.062, 1.158) and a 10% increase in HHI resulting in 6.6% lower likelihood (adjusted odds ratio = 0.936; 95% CI = 0.880, 0.996). Price models indicated that the price of laparoscopy was 7.6% lower than that of open surgery (transformed coefficient = 0.927; 95% CI = 0.895, 0.960). A 10% increase in HMO penetration was associated with 1.6% lower price (transformed coefficient = 0.985; 95% CI = 0.977, 0.992), whereas a 10% increase in HHI was associated with 1.6% higher price (transformed coefficient = 1.016; 95% CI = 1.006, 1.027; P < .001 for all comparisons).

CONCLUSIONS

Laparoscopy was significantly associated with lower hospital prices. Moreover, laparoscopic surgery may result in cost savings, while market pressures contribute to its adoption.

International trends in surgical treatment of rectal cancer

BACKGROUND

Surgical technique might influence rectal cancer survival, yet international practices for surgical treatment of rectal cancer are poorly described.

METHODS

We performed a cross-sectional survey in a cohort of experienced colorectal surgeons representing 123 centers.

RESULTS

Seventy-one percent responded, 70% are from departments performing more than 50 proctectomies annually. More than 50% defined the rectum as "15 cm from the verge." Seventy-two percent perform laparoscopic proctectomy, 80% use oral bowel preparation, 69% perform high ligation of the inferior mesenteric artery, 76% divert stomas as routine for colo-anal anastomosis, and 63% use enhanced recovery protocols. Different practices exist between US and non-US surgeons: 15 cm from the verge to define the rectum (34% vs 59%; P = .03), personally perform laparoscopic resection (82% vs 66%; P = .05), rectal stump washout (36% vs 73%; P = .0001), always drain after surgery (23% vs 42%; P = .03), transanal endoscopic microsurgery for T2N0 in medically unfit patients (39% vs 61%; P = .0001).

CONCLUSIONS

Wide international variations in rectal cancer management make outcome comparisons challenging, and consensus development should be encouraged.

International preoperative rectal cancer management: staging, neoadjuvant treatment, and impact of multidisciplinary teams

BACKGROUND

Little is known regarding variations in preoperative treatment and practice for rectal cancer (RC) on an international level, yet practice variation may result in differences in recurrence and survival rates.

METHODS

One hundred seventy-three international colorectal centers were invited to participate in a survey of preoperative management of rectal cancer.

RESULTS

One hundred twenty-three (71%) responded, with a majority of respondents from North America, Europe, and Asia. Ninety-three percent have more than 5 years' experience with rectal cancer surgery. Fifty-five percent use CT scan, 35% MRI, 29% ERUS, 12% digital rectal examination and 1% PET scan in all RC cases. Seventy-four percent consider threatened circumferential margin (CRM) an indication for neoadjuvant treatment. Ninety-two percent prefer 5-FU-based long-course neoadjuvant chemoradiation therapy (CRT). A significant difference in practice exists between the US and non-US surgeons: poor histological differentiation as an indication for CRT (25% vs. 7.0%, p = 0.008), CRT for stage II and III rectal cancer (92% vs. 43%, p = 0.0001), MRI for all RC patients (20% vs. 42%, p = 0.03), and ERUS for all RC patients (43% vs. 21%, p = 0.01). Multidisciplinary team meetings significantly influence decisions for MRI (RR = 3.62), neoadjuvant treatment (threatened CRM, RR = 5.67, stage II + III RR = 2.98), quality of pathology report (RR = 4.85), and sphincter-saving surgery (RR = 3.81).

CONCLUSIONS

There was little consensus on staging, neoadjuvant treatment, and preoperative management of rectal cancer. Regular multidisciplinary team meetings influence decisions about neoadjuvant treatment and staging methods.

Chronic abdominal wall pain--a diagnostic challenge for the surgeon

BACKGROUND

Chronic abdominal wall pain (CAWP) occurs in about 30% of all patients presenting with chronic abdominal pain.

METHODS

The authors review the literature identified in a PubMed search regarding the abdominal wall as the origin of chronic abdominal pain.

RESULTS

CAWP is frequently misinterpreted as visceral or functional abdominal pain. Misdiagnosis often leads to a variety of investigational procedures and even abdominal operations with negative results. With a simple clinical test (Carnett's test), >90% of patients with CAWP can be recognized, without risk for missing intra-abdominal pathology.

CONCLUSION

The condition can be confirmed when the injection of local anesthetics in the trigger point(s) relieves the pain. A fasciotomy in the anterior abdominal rectus muscle sheath through the nerve foramina of the affected branch of one of the anterior intercostal nerves heals the pain.

Anastomotic leakage after laparoscopic protectomy can be managed by a minimally invasive approach

PURPOSE

This study was designed to identify the clinical features of anastomotic leakage after laparoscopic resection of rectal cancer and to evaluate the outcomes of laparoscopic management for this problem.

METHODS

Prospectively collected data were obtained from 307 patients with rectal cancer who underwent laparoscopic proctectomy and primary anastomosis. Age, sex, tumor location, tumor stage, body mass index, comorbidities, ileostomy, conversion, intraoperative blood loss, operative time, previous abdominal operation, and hospital stay were analyzed for patients with or without anastomotic leakage. Management and outcome of anastomotic leakage also were analyzed.

RESULTS

Anastomotic leakage occurred in 29 patients (9.4 percent). Diverting ileostomy was initially fashioned in 65 patients (21.2 percent). Leakage was related to young age, male sex, lower tumor location, and longer operation time. Ten patients (34.5 percent) were successfully managed with conservative treatment. Seventeen patients (58.6 percent) were managed via a laparoscopic approach. Open surgery was performed in two patients who showed diffuse fecal soiling or had previous conversion, respectively. There was no mortality.

CONCLUSIONS

When leakage occurs, laparotomy or colostomy is not needed routinely. For surgical intervention, the abdominal cavity should be explored first by laparoscopic visualization because the majority of patients can be successfully managed with laparoscopy and ileostomy.

Standardized postoperative pathway: accelerating recovery after ileostomy closure

PURPOSE

In this study we evaluated the outcome of a standardized enhanced recovery program in patients undergoing ileostomy closure.

METHODS

Forty-two patients underwent ileostomy closure by a single surgeon and were managed by a standardized postoperative care pathway. On the first postoperative day, patients received oral analgesia and a soft diet. Discharge was based on standard criteria previously published for laparoscopic colectomy patients. Results were recorded prospectively in an Institutional Review Board-approved database, including demographics, operative time, blood loss, complications, length of stay, and readmission data.

RESULTS

The median operative time and blood loss were 60 minutes and 17.5 mL, respectively, and median hospital stay was 2 days. Twenty-nine patients (69 percent) were discharged by postoperative Day 2. The complication rate was 23.8 percent; complications included prolonged postoperative ileus (n = 3), early postoperative small-bowel obstruction (n = 1), mortality not related to ileostomy closure (n = 1), minor bleeding (n = 1), wound infection (n = 1), incisional hernia (n = 1), diarrhea (n = 1), dehydration (n = 1). The 30-day readmission rate was 9.5 percent (n = 4). Two patients had reoperation within 30 days for small-bowel obstruction and a wound infection.

CONCLUSIONS

Ileostomy closure patients managed with postoperative care pathways can have a short hospital stay with acceptable morbidity and readmission rates.

Uncemented total hip arthroplasty in osteonecrosis: a 2- to 10-year evaluation

All patients undergoing uncemented total hip arthroplasty for end stage hip disease related to osteonecrosis of the femoral head were assessed prospectively between November 1983 and October 1992. The results of clinical evaluation using the Harris Hip score and radiographic assessment of fixation were analyzed to identify features of success or failure that may be unique to this population. Four different stem types and 4 different acetabular components were used. Sixty-four patients had 98 hips implanted during the time of the study. The 42 male and 22 female patients averaged 41 years of age (range, 21-69 years). Average followup was 87.3 months (7.3 years; range, 31-134 months). The cause of osteonecrosis was corticosteroids (42 hips), alcohol (27 hips), trauma (5 hips), and other (24 hips). Three patients (5 hips) have died and 4 patients (6 hips) are lost to followup. At last followup 65 of 87 hips (75%) remained radiographically stable and clinically functional, 18 of 87 (21%) have been revised, and 4 were failing (osteolysis). Of the 22 hips with revision or impending failure, 4 were for technical reasons on the femoral side and 18 were for acetabular wear. Patient factors such as weight or underlying disease state did not seem to influence the ability to achieve stable fixation or contribute to accelerated failure. Failures related primarily to problems of first generation devices including accelerated wear of acetabular components, technical issues of femoral component placement (undersizing of components or femoral fracture), and the use of noncircumferentially coated femoral components. Age may be a factor in early failure. This 10-year experience with total hip arthroplasty for the patient with end stage hip disease due to osteonecrosis suggests that uncemented total hip arthroplasty can be applied predictably to this younger, potentially more active patient population.