Factors Affecting the Duration of Surgery in the Management of Condylar Head Fractures

Prolonged operation times should be avoided due to the associated complications and negative effects on the efficiency of the use of operating room resources. Surgical treatment of mandibular condylar head fractures is a well-established routine procedure at our department, nevertheless, we recognized fluctuating operating times. This study aims to pinpoint the influencing factors, in particular the hypothesis whether the efficiency of intraoperative muscle relaxation may decisively affect the duration of surgery. It analyses 168 mandibular condylar head fractures that were surgically treated in the period from 2007 to 2022 regarding the duration of the surgery and potential factors affecting it. The potential predictors' influence on the dependent variable operation time was mainly calculated as a bivariate analysis or linear regression. Efficiency of relaxation (p ≤ 0.001), fragmentation type (p = 0.031), and fracture age (p = 0.003) could be identified as decisive factors affecting the duration of surgery, as the first surgeon was a constant. In conclusion, surgical intervention should start as soon as possible after a traumatic incident. In addition, a dosage regimen to optimize the efficiency of relaxation should be established in future studies. Fragmentation type and concomitant fractures should also be considered for a more accurate estimation of the operating time.

Impact of operation duration on postoperative outcomes of minimally-invasive right colectomy

AIM

Operation time (OT) is a key operational factor influencing surgical outcomes. The present study aimed to analyse whether OT impacts on short-term outcomes of minimally-invasive right colectomies by assessing the role of surgical approach (robotic [RRC] or laparoscopic right colectomy [LRC]), and type of ileocolic anastomosis (i.e., intracorporal [IA] or extra-corporal anastomosis [EA]).

METHODS

This was a retrospective analysis of the Minimally-invasivE surgery for oncological Right ColectomY (MERCY) Study Group database, which included adult patients with nonmetastatic right colon adenocarcinoma operated on by oncological RRC or LRC between January 2014 and December 2020. Univariate and multivariate analyses were used.

RESULTS

The study sample was composed of 1549 patients who were divided into three groups according to the OT quartiles: (1) First quartile, <135 min (n = 386); (2) Second and third quartiles, 135-199 min (n = 731); and (3) Fourth quartile ≥200 min (n = 432). The majority (62.7%) were LRC-EA, followed by LRC-IA (24.3%), RRC-IA (11.1%), and RRC-EA (1.9%). Independent predictors of an OT ≥ 200 min included male gender, age, obesity, diabetes, use of indocyanine green fluorescence, and IA confection. An OT ≥ 200 min was significantly associated with an increased risk of postoperative noninfective complications (AOR: 1.56; 95% CI: 1.15-2.13; p = 0.004), whereas the surgical approach and the type of anastomosis had no impact on postoperative morbidity.

CONCLUSION

Prolonged OT is independently associated with increased odds of postoperative noninfective complications in oncological minimally-invasive right colectomy.

Operating Time: An Independent and Modifiable Risk Factor for Short-Term Complications after Videothoracoscopic Pulmonary Lobectomy

OBJECTIVES

The relationship between operating time and postoperative morbidity has not been fully characterized in lung resection surgery. We aimed to determine the variables associated to prolonged OT and their influence on postoperative complications after video-thoracoscopic lobectomy.

METHODS

Patients undergoing thoracoscopic lobectomy for lung cancer from December 2016 to March 2018, within the prospective registry of the Spanish Video-Assisted Thoracic Surgery Group were identified. Operating time was stratified by quartiles and complication rates analysed using chi-squared test. Primary outcomes included 30-day overall, pulmonary, and cardiovascular complications and wound infection. Multivariable logistic regression analyses were performed to identify variables independently associated to operating time and their influence on the occurrence of postoperative complications.

RESULTS

Data of 1518 cases were examined. Median operating time was 174 minutes (interquartile range: 130-210 minutes). Overall morbidity rates significantly increased with surgical duration (20.5% versus 34.4% in the 1st and 4th quartile, respectively, p < 0.05) and so did pulmonary complications (14.6% versus 26.4% in the 1st and 4th quartile, respectively, p < 0.05). Differences were not found regarding cardiovascular and wound complications. After multivariable logistic regression analysis, operating time remained as an independent risk factor for overall (OR, 2.05) and pulmonary complications (OR, 2.01). Male sex, ppoDLCO%, number of lymphatic stations harvested, pleural adhesions, fissures completeness, lobectomy site, surgeon seniority, individual video-thoracoscopic surgeon experience and fissureless technique were identified as predictive factors for long operative time.

CONCLUSION

Prolonged operating time is associated with increased odds of postoperative complications. Modifiable factors contributing to prolonged operating time may serve as a target for quality improvement.

Operating time for wire ligation with self-ligating and conventional brackets: A standardized in vitro study

OBJECTIVE

Operating time is one of the main advantages attributed from the literature to the use of self-ligating brackets (SLB). The aim of this study is to investigate the time needed for a complete archwire change procedure with conventional brackets (CB) and SLBs in a standardized in vitro research setting, comparing operators with different expertise.

MATERIALS AND METHODS

Thirty-three participants were divided into three equal groups: undergraduate students, postgraduate students, and orthodontists. Three sets of typodonts bonded with three types of brackets, including passive SLBs, active SLBs, and CBs using both steel and elastic ligatures were investigated. Operators had to insert, ligate, deligate, and remove wires in sets of typodonts representing an actual dentition before and after orthodontic treatment, mounted in phantoms. Archwire change procedure times were compared between the different bracket/ligation systems, between the before- and after-treatment typodonts, and between operators.

RESULTS

There were significant differences between SLBs and CBs, the greatest difference being 11 min 16 s between passive SLBs and CBs ligated with metallic ligatures at T0, for the total archwire change procedure by the operators overall. For all the operators, there was a statistically significant difference in total archwire change procedure time between the systems. The undergraduate students were the slowest when using CBs, but they showed no significant difference compared to the other users when using SLBs.

CONCLUSION

SLBs can offer a significant operating time reduction compared to CBs, and time saving is not dependent on the operator's experience and training.

Describing the spine surgery learning curve during the first two years of independent practice

Retrospective cohort studyTo characterize the learning curve of a spine surgeon during the first 2 years of independent practice by comparing to an experienced colleague. To stratify learning curves based on procedure to evaluate the effect of experience on surgical complexity.The learning curve for spine surgery is difficult to quantify, but is useful information for hospital administrators/surgical programs/new graduates, so appropriate expectations and accommodations are considered.Data from a retrospective cohort (2014-2016) were analyzed at a quaternary academic institution servicing a geographically-isolated, mostly rural area. Procedures included anterior cervical discectomy and fusion, posterior cervical decompression and stabilization, single and 2-level posterior lumbar interbody fusion, lumbar discectomy, and laminectomy. Data related to patient demographics, after-hours surgery, and revision surgery were collected. Operative time was the primary outcome measure, with secondary measures including cerebrospinal fluid leak and early re-operation. Time periods were stratified into 6 month quarters (quarter [Q] 1-Q4), with STATA software used for statistical analysis.There were 626 patients meeting inclusion criteria. The senior surgeon had similar operative times throughout the study. The new surgeon demonstrated a decrease in operative time from Q1 to Q4 (158 minutes-119 minutes, P < .05); however, the mean operative time was shorter for the senior surgeon at 2 years (91 minutes, P < .05). The senior surgeon performed more revision surgeries (odds ratio [OR] 2.5 [95% confidence interval [CI] 1.7-3.6]; P < .001). Posterior interbody fusion times remained longer for the new surgeon, while laminectomy surgery was similar to the senior surgeon by 2 years. There were no differences in rates of cerebrospinal fluid leak (OR 1.2 [95% CI 0.6-2.5]; P > .05), nor reoperation (OR 1.16 [95% CI 0.7-1.9]; P > .05) between surgeons.A significant learning curve exists starting spine practice and likely extends beyond the first 2 years for elective operations.

Surgical and Patient Outcomes of Robotic Versus Conventional Laparoscopic Hysterectomy: A Systematic Review

Hysterectomy is a commonly performed gynecologic surgery that can be associated with significant morbidity and mortality. However, the evolution of the surgical approach, from open to minimally invasive gynecologic surgery (MIGS), has substantially improved patient outcomes by reducing perioperative complications, pain, and length of hospitalization. The evident advantages and the approval of the da Vinci Surgical System by the Food and Drug Administration led to the exponential rise in the use of MIGS. In particular, robotic hysterectomy (RH) witnessed unparalleled popularity compared to other MIGS despite the lack of strong evidence demonstrating its superiority. Therefore, we conducted a systematic review of the literature to evaluate and compare various patient and surgical outcomes of RH with conventional laparoscopic hysterectomy (CLH), including operating time, estimated blood loss, length of hospitalization, overall complications, survival, and cost. Overall, the outcomes were comparable between RH and CLH except concerning cost. RH is significantly more expensive than CLH due to the higher costs of robotic equipment, including disposable instruments, equipment maintenance, and sterilization. Although RH demonstrated comparable outcomes and higher costs, its technical advantages such as improved ergonomics, three-dimensional view, a wider range of wristed mobility, mechanical lifting of robot's hand, and greater stability might benefit patient subsets (e.g., obesity, large uterine weights >750 g). Therefore, large and multicentered randomized control trials are imperative to determine the most effective surgical approach between RH and other MIGS for different patient subsets.

One surgeon's learning curve with single position lateral lumbar interbody fusion: perioperative outcomes and complications

BACKGROUND

Single position (SP) lateral transpsoas lumbar interbody fusion (LLIF) with posterior pedicle screw fixation (PPSF) reduces operative time compared to dual positioning. However, the learning curve has not yet been described. The purpose of this study was to define the learning curve SP LLIF with PPSF.

METHODS

This retrospective case series included the first 161 consecutive patients who underwent SP LLIF and PPSF with the senior author. Primary analysis of operative time versus case number included single level cases without adjacent level procedures. Secondary analyses included 1-3 level cases without adjacent level procedures. Operative time for 2 and 3 level procedures was normalized to single-level cases. The learning curve was assessed with linear regression, which was found to fit the data better than logarithmic regression as judged by R² values and data visualization. Perioperative outcomes as a function of case number were analyzed by least squares linear regression and Mann Whitney U-tests.

RESULTS

For single level surgeries without adjacent procedures (n=87), operative time decreased by a total of 28.7 (95% CI, 9.6, 47.9) minutes over the series (P<0.001). For 1-3 level cases with no adjacent procedures (n=131), normalized operative time decreased by 23.1 (7.6, 38.6) minutes (P<0.001). Post-operative change in hematocrit, length of hospital stay, post-operative change in lordosis, 90-day complications, suboptimal screw placement, and 6-week post-operative Oswestry Disability Index (ODI) score did not correlate with case number. Intraoperative fluids decreased 3.7 mL (95% CI, 0.7, 6.7) per case (P=0.015).

CONCLUSIONS

In SP LLIF with PPSF, case number correlated with decreased operative time, but not complications. The surgeon's prior experience with dual position (DP) LLIF likely contributed to the minimal learning curve observed. Surgeons adopting SP LLIF with minimal prior DP LLIF experience may experience a steeper curve.

The learning curve of robotic-arm assisted acetabular cup positioning during total hip arthroplasty

BACKGROUND

Robotic-arm assisted surgery aims to reduce manual errors and improve the accuracy of implant positioning and orientation during total hip arthroplasty (THA). The objective of this study was to assess the surgical team's learning curve for robotic-arm assisted acetabular cup positioning during THA.

METHODS

This prospective cohort study included 100 patients with symptomatic hip osteoarthritis undergoing primary total THA performed by a single surgeon. This included 50 patients receiving conventional manual THA and 50 patients undergoing robotic-arm assisted acetabular cup positioning during THA. Independent observers recorded surrogate markers of the learning curve including operative times, confidence levels amongst the surgical team using the state-trait anxiety inventory (STAI) questionnaire, accuracy in restoring native hip biomechanics, acetabular cup positioning, leg-length discrepancy, and complications within 90 days of surgery.

RESULTS

Cumulative summation (CUSUM) analysis revealed robotic-arm assisted acetabular cup positioning during THA was associated with a learning curve of 12 cases for achieving operative times (p < 0.001) and surgical team confidence levels (p < 0.001) comparable to conventional manual THA. There was no learning curve of robotic-arm assisted THA for accuracy of achieving the planned horizontal (p = 0.83) and vertical (p = 0.71) centres of rotation, combined offset (p = 0.67), cup inclination (p = 0.68), cup anteversion (p = 0.72), and correction of leg-length discrepancy (p = 0.61). There was no difference in postoperative complications between the two treatment groups.

CONCLUSIONS

Integration of robotic-arm assisted acetabular cup positioning during THA was associated with a learning curve of 12 cases for operative times and surgical team confidence levels but there was no learning curve effect for accuracy in restoring native hip biomechanics or achieving planned acetabular cup positioning and orientation.

A meta-analysis of DaVinci Si versus Xi in colorectal surgery

BACKGROUND

The aim of this meta-analysis was to evaluate whether adoption of DaVinci Xi^® had any impact upon intra- and postoperative metrics in colorectal surgery.

METHODS

The Pubmed, CINAHL, Cochrane Library and MEDLINE (Ovid) databases were systematically searched. Operating time as well as docking and surgeon console times were the primary endpoints. Conversion and postoperative complication rates were the secondary endpoints.

RESULTS

Six studies totaling 610 patients (320 Si and 290 Xi) were included. Total operating time [MD (95% CI) = 30.553 (15.071, 46.035); p < 0.001], docking time [MD (95% CI) = 4.178 (2.120, 6.235); p < 0.001] and surgeon console time [MD (95% CI) = 17.246 (-0.479, 34.971); p = 0.056] were longer in DaVinci Si^® as compared to DaVinci Xi^® . No significant difference was found in conversion (p = 0.816) and postoperative complication rates (p = 0.405).

CONCLUSION

This meta-analysis found that the adoption of DaVinci Xi^® was associated with significantly decreased total operating time as well as docking and surgeon console times. Conversion and complication rates were similar.

Factors Affecting Total Operating Time in Patients Undergoing Mastectomy With and Without Reconstruction

BACKGROUND

Operating room (OR) time varies significantly in patients undergoing mastectomy. We sought to determine factors influencing OR time such that more accurate predictions could be made.

METHODS

Records of patients undergoing mastectomy at our institution between January 2010 and June 2018 were reviewed. Operating Room time was defined as time from incision to dressing. Nonparametric analyses were performed to determine factors associated with OR time. A predictive model using linear regression was created on a training set and evaluated in a separate testing set.

RESULTS

Our cohort included 1008 female patients who underwent either unilateral or bilateral mastectomy (BM), with or without reconstruction, and with or without concomitant axillary lymph node staging at our institution. The median OR time was 4.67 hours (range; .70-16.35 hours). To create a predictive model, we divided our cohort into a training set of 504 patients and a testing set of 504 patients. Across the training set, body mass index (BMI), BM, nonconventional mastectomies, intraoperative frozen sections, receipt of neoadjuvant chemotherapy, and reconstruction were associated with longer OR times on linear regression. A model generated from these findings on the training set was run on the testing set (Pearson correlation = .743 for predicted vs. actual OR times, P < .001).

CONCLUSION

A number of preoperative factors such as BMI, unilateral vs. BM, type of mastectomy and reconstruction, use of intraoperative frozen sections, and receipt of neoadjuvant chemotherapy can influence OR times. Accurate predictions can be made using a simple model incorporating these factors.

Is low or high body mass index in patients operated for oral squamous cell carcinoma associated with the perioperative complication rate?

The aim of this study was to analyse the effect of body mass index (BMI), both low and high values, on the perioperative complication rate in patients with oral squamous cell carcinoma (OSCC). The medical records of 259 patients operated between 2014 and 2017 for OSCC were reviewed. Univariate and multivariate analyses were performed. Sixty of the 259 patients developed 87 complications. Low or high BMI was not associated with the perioperative complication rate. A longer operating time and increased blood loss were associated with a higher perioperative complication rate and higher Clavien-Dindo grade. Low BMI, American Society of Anesthesiologists score 2 and 3, a longer operating time, and increased blood loss were associated with a longer hospital stay. Low BMI was associated with a longer hospital stay. Neither low nor high BMI was associated with the perioperative complication rate. A longer operating time and increased blood loss were associated with a higher perioperative complication rate and higher Clavien-Dindo grade.

Single position versus lateral-then-prone positioning for lateral interbody fusion and pedicle screw fixation

Background

To compare perioperative and radiographic outcomes following lateral lumbar interbody fusions in two cohorts of patients who either underwent single position or dual position surgery.

Methods

Patients over the age of 18 with degenerative lumbar pathology who underwent a lumbar interbody fusion via lateral access from 2012-2015 from a single surgeon met inclusion criteria. Patients who underwent combined procedures, had a history of retroperitoneal surgery, or had inadequate preoperative imaging were excluded. Patients who remained in the lateral decubitus position for pedicle screw fixation [single-position (SP)] were compared to those turned prone [dual-position (DP)]. Demographics, surgical details, and perioperative outcomes were compared between groups.

Results

A total of 42 SP and 24 DP patients were analyzed. The DP group had a 44.4-minute longer operating room time compared to the SP group (P<0.001) after adjusting for the number of levels operated (P<0.001) and unilateral versus bilateral screw placement (P=0.048). Otherwise, no differences were observed in peri-operative outcomes. Lordosis was not different between groups pre-operatively (P>0.999) or post-operatively (P=0.479), and neither was the pre- to post-operative change (P=0.283).

Conclusions

Lateral pedicle screw fixation following lateral interbody fusion decreases operating room time without compromising post-operative lordosis, complication rates, or perioperative outcomes.

Procedure costs associated with the use of Harmonic devices compared to conventional techniques in various surgeries: a systematic review and meta-analysis

Background

As compared to conventional techniques, recent meta-analyses have reported cost savings with Harmonic devices; however, only in thyroidectomy. Thus, the aim of this study was to evaluate the costs associated with Harmonic devices versus conventional techniques across a range of surgical procedures.

Methods

A systematic search of MEDLINE, EMBASE, and Cochrane Library was conducted from inception to October 01, 2016 without language restrictions to identify randomized controlled trials comparing Harmonic devices to conventional techniques and reporting procedure costs (operating time plus operating equipment/consumables/device costs). Costs were pooled using the ratio of geometric means, and a random effects model was applied. Sensitivity analyses varying statistical methods, number of included studies, and cost outcomes were completed to test the robustness of the results.

Results

Thirteen studies met the inclusion criteria. A total of 561 and 540 participants had procedures performed with Harmonic devices and conventional methods, respectively, with procedures including gastrectomy, thyroidectomy, colectomy, cholecystectomy, Nissen fundoplication, and pancreaticoduodenectomy. As compared to conventional methods, Harmonic devices reduced total procedure costs by 8.7% (p=0.029), resulting in an absolute reduction of US$227.77 from mean conventional technique costs, derived primarily from a reduction in operating time costs. When operating time costs, excluding operating equipment/consumables/device costs, were analyzed, costs were reduced by $544 per procedure with the use of Harmonic devices. The results from all sensitivity analyses demonstrated cost reductions with Harmonic devices.

Conclusion

This systematic review and meta-analysis showed that despite a higher device cost, Harmonic devices provide a statistically significant reduction in procedure costs, derived primarily from a reduction in operating time costs, across surgical procedures. In addition to functionality benefits, Harmonic devices may represent a potentially cost saving method to reduce overall hospital resource use. Future research should focus on potential costs and benefits from use of Harmonic devices in procedures not covered here.

Factors affecting the operating time for complete cyst excision and Roux-en-Y hepaticojejunostomy in paediatric cases of congenital choledochal malformation: a retrospective case study in Southeast China

OBJECTIVE

The aim of this study was to evaluate factors affecting the operating time for complete cyst excision and Roux-en-Y hepaticojejunostomy in paediatric cases of congenital choledochal malformation (CCM).

DESIGN

A 3-year retrospective study was undertaken between January 2013 and December 2015 in four centres in China.

SETTING

This involved a retrospective chart review of paediatric patients with CCM in four large hospitals in Southeast China.

PARTICIPANTS

Sixty-five paediatric patients with CCM were included in this study. We derived all available information on patient demographics, clinical characteristics, preoperative complications and surgical methods from the charts of all these patients.

INTERVENTIONS

Univariate and multivariate logistic regression analyses were used to evaluate factors significantly affecting the operating time for complete cyst excision and Roux-en-Y hepaticojejunostomy in paediatric cases of CCM.

RESULTS

Twenty-three of the 65 case surgeries were performed using laparoscopic technique, and 42 surgeries were performed by conventional open surgery. The median operating time was 215 min (range 120-430 min). The morphological subtype of CCM and the presence of cholecystitis or cholangitis were the only factors found to affect the operating time (p<0.05). Logistic regression analysis confirmed cholangitis as an independent risk factor.

CONCLUSIONS

The morphological subtype of CMM and the presence of cholecystitis or cholangitis are factors affecting the operating time for complete cyst excision and Roux-en-Y hepaticojejunostomy in paediatric cases of CCM, whereas cholangitis is an independent risk factor.

A comparison of 2 cesarean section methods, modified Misgav-Ladach and Pfannenstiel-Kerr: A randomized controlled study

BACKGROUND

The modified Misgav-Ladach method (MML) is a minimally invasive cesarean section procedure compared with the classic Pfannenstiel-Kerr (PK) method.

OBJECTIVES

The aim of the study was to compare the MML method and the PK method in terms of intraoperative and short-term postoperative outcomes.

MATERIAL AND METHODS

This prospective, randomized controlled trial involved 252 pregnant women scheduled for primary emergency or elective cesarean section between October, 2014 and July, 2015. The primary outcome measures were the duration of surgery, extraction time, Apgar score, blood loss, wound complications, and number of sutures used. Secondary outcome measures were the wound infection, time of bowel restitution, visual analogue scale (VAS) scores at 6 h and 24 h after the operation, limitations in movement, and analgesic requirements. At 6 weeks after surgery, the patients were evaluated regarding late complications.

RESULTS

There was a significant reduction in total operating and extraction time in the MML group (p < 0.001). Limitations in movement were lower at 24 h after the MML operation, and less analgesic was required in the MML group. There was no difference between the 2 groups in terms of febrile morbidity or the duration of hospitalization. At 6 weeks after the operation, no complaints and no additional complications from the surgery were noted.

CONCLUSIONS

The MML method is a minimally invasive cesarean section. In the future, as surgeons' experience increases, MML will likely be chosen more often than the classic PK method.

Harmonic Scalpel-Assisted Laparoscopic Cholecystectomy vs. Conventional Laparoscopic Cholecystectomy - A Non-randomized Control Trial

Introduction

Laparoscopic cholecystectomy (LC) is the most commonly done, minimally invasive surgical procedure. Routinely used electrocautery produces more smoke, which masks the operating field, thereby prolongs the surgery and posing an increased risk of gallbladder (GB) perforation. The titanium clips used for clipping the cystic artery and cystic duct have a risk of slippage, which may lead to bleeding, and an increased risk for bile leakage. In addition, it may act as a nidus for stone formation. Advanced energy sources, such as the harmonic scalpel, though expensive, may provide the advantage of shorter operating time by reducing smoke, bloodless dissection in the GB bed, lower risk of bleeding from the cystic artery due to secure vessel sealing, and avoiding the use of a larger number of titanium clips. However, evidence to substantiate this advantage is limited.

Aim

To compare the operating time and perioperative complications between conventional laparoscopic cholecystectomy (CLC) and harmonic scalpel assisted laparoscopic cholecystectomy (HLC).

Methodology

All consecutive patients who underwent elective LC were included. Patients with acute infection, impaired liver function tests, concomitant common bile duct calculi, chronic liver disease/cirrhosis, suspected GB carcinoma, and pregnant women were excluded from the study. Patients were allocated into two groups. In the CLC group, both the cystic duct and the cystic artery were divided after conventional titanium clip application and electrocautery was used for thermal energy. In the HLC group, the cystic duct was clipped with a titanium clip and the rest of the procedure was carried out using Harmonic Ace (Ethicon, New Jersey, United States) and Harmonic Hook (Ethicon, New Jersey, United States). Outcome parameters analyzed were operating time in minutes, post-operative pain using visual analogue scale (VAS) scoring, frequency and route of analgesic requirement after 24 hours, and intraoperative complications, including bleeding, bile duct injury, GB perforation, and surgical site infection (SSI) in the postoperative period, per the Centers for Disease Control (CDC) criteria.

Results

Both the groups were comparable with respect to age, gender, body mass index (BMI), and the presence of comorbidity and an indication of cholecystectomy. The duration of surgery did not significantly differ between the groups (67.3 vs. 64.3 mins; p = 0.30). Other parameters, such as analgesic required on postoperative Day 1 (3.2 vs. 3; p = 0.67), VAS scores on Day 0 (4.55 vs. 4.65; p = 0.59), VAS scores on Day 1 (2.3 vs. 2.2; p = 0.84), superficial SSI (15% vs. 10%; p = 0.63), intraoperative GB perforation (30% vs. 20%; p = 0.71), and intraperitoneal drain (30% vs. 20%; p = 0.71) did not significantly differ between the groups.

Conclusion

HLC has no significant advantage over CLC with respect to operating time, postoperative pain, and perioperative complications.

Pelvic examination may be meaningfully taught to novices and be used to predict operating times for laparoscopic excision of endometriosis in one surgical procedure

OBJECTIVE

To investigate whether pelvic examination may be meaningfully taught to novice medical students and its accuracy in predicting operating times for laparoscopic excision of endometriosis at a single surgical procedure.

METHODS

Women with suspected endometriosis scheduled for laparoscopy underwent pelvic examination to estimate operative time by medical students (novices), trainees, senior clinicians with <10 years surgical experience (experts) and ≥10 years (masters). Examination and intraoperative findings were compared and stage of disease recorded.

RESULTS

There were 138 estimations of operating time at the initial assessment and 251 estimations of operating time prior to surgery. The median surgical duration was 44 min (range 12-398) and increased progressively with revised American Society for Reproductive Medicine disease stage. Clinical predictions exceeded actual operating times by a median of 18 min (range overestimating by 180 min and underestimating by 120 min) with 80% of procedures completed in less time than predicted and none requiring a second procedure. There was no statistical difference in operative time estimations between the groups with students and trainees underestimating surgical duration by a median of two and five minutes, respectively, experts having a median time difference of zero minutes, and masters overestimating by 4.5 min.

CONCLUSION

Targeted pelvic examining may be taught to novices (medical students) and can be used to predict operating time at one surgical procedure. Less experienced examiners have a tendency to underestimate surgical duration, with masters overestimating surgical time when scheduling laparoscopies for endometriosis, and increasing disease stage is associated with a less precise estimation of surgical duration.

Oncoplastic round block technique has comparable operative parameters as standard wide local excision: a matched case-control study

BACKGROUND

Although oncoplastic breast surgery is used to resect larger tumors with lower re-excision rates compared to standard wide local excision (sWLE), criticisms of oncoplastic surgery include a longer-albeit, well concealed-scar, longer operating time and hospital stay, and increased risk of complications. Round block technique has been reported to be very suitable for patients with relatively smaller breasts and minimal ptosis. We aim to determine if round block technique will result in operative parameters comparable with sWLE.

METHODS

Breast cancer patients who underwent a round block procedure from 1st May 2014 to 31st January 2016 were included in the study. These patients were then matched for the type of axillary procedure, on a one to one basis, with breast cancer patients who had undergone sWLE from 1st August 2011 to 31st January 2016. The operative parameters between the 2 groups were compared.

RESULTS

22 patients were included in the study. Patient demographics and histologic parameters were similar in the 2 groups. No complications were reported in either group. The mean operating time was 122 and 114 minutes in the round block and sWLE groups, respectively (P=0.64). Length of stay was similar in the 2 groups (P=0.11). Round block patients had better cosmesis and lower re-excision rates. A higher rate of recurrence was observed in the sWLE group.

CONCLUSION

The round block technique has comparable operative parameters to sWLE with no evidence of increased complications. Lower re-excision rate and better cosmesis were observed in the round block patients suggesting that the round block technique is not only comparable in general, but may have advantages to sWLE in selected cases.

Ambulatory movements, team dynamics and interactions during robot-assisted surgery

OBJECTIVE

To analyse ambulatory movements and team dynamics during robot-assisted surgery (RAS), and to investigate whether congestion of the physical space associated with robotic technology led to workflow challenges or predisposed to errors and adverse events.

METHODS

With institutional review board approval, we retrospectively reviewed 10 recorded robot-assisted radical prostatectomies in a single operating room (OR). The OR was divided into eight zones, and all movements were tracked and described in terms of start and end zones, duration, personnel and purpose. Movements were further classified into avoidable (can be eliminated/improved) and unavoidable (necessary for completion of the procedure).

RESULTS

The mean operating time was 166 min, of which ambulation constituted 27 min (16%). A total of 2 896 ambulatory movements were identified (mean: 290 ambulatory movements/procedure). Most of the movements were procedure-related (31%), and were performed by the circulating nurse. We identified 11 main pathways in the OR; the heaviest traffic was between the circulating nurse zone, transit zone and supply-1 zone. A total of 50% of ambulatory movements were found to be avoidable.

CONCLUSION

More than half of the movements during RAS can be eliminated with an improved OR setting. More studies are needed to design an evidence-based OR layout that enhances access, workflow and patient safety.

Neoadjuvant hormone therapy following treatment with robotic-assisted radical prostatectomy achieved favorable in high-risk prostate cancer

Purpose

Patients with a high risk of prostate carcinoma typically have higher rates of positive surgical margins and biochemical failure following radical prostatectomy and adjuvant hormone therapy. In this study, we assessed the effects of neoadjuvant hormone therapy (NHT) on prostate carcinoma in high-risk patients following robotic-assisted radical prostatectomy (RARP).

Methods

This retrospective study investigated the medical records of 28 patients who underwent RARP between January 2009 and October 2013. Twenty-two patients underwent NHT prior to RARP. Furthermore, six patients did not undergo NHT prior to RARP. Parameters including age, operating time, blood loss, blood transfusion status, and cancer stage were checked against anatomical correlations. Potential predictors of prolonged operating time and prolonged surgical procedures were assessed using multiple logistic regressions.

Results

NHT was shown to be an independent predictor of prolonged total operating time. Tumor stage alterations did not appear to be associated with NHT followed by RARP. The patients who underwent NHT were not more likely to have positive surgical margins, and an increase in patients requiring blood transfusion was not seen.

Conclusion

NHT appears to increase operative time during RARP. However, the perioperative morbidity of NHT patients undergoing RARP appears to be equivalent with that of non-NHT patients.

Uterine artery ligation at the beginning of total laparoscopic hysterectomy reduces total blood loss and operation duration

The purpose of this study was to compare the feasibility, blood loss, duration of surgery and complications between patients in whom both uterine arteries were ligated by surgical clips and cut using a 5-mm ligature at the beginning of total laparoscopic hysterectomy (TLH) and patients in whom uterine arteries were not ligated at the beginning of TLH. In our prospective study, a total of 60 women underwent TLH. Uterine artery ligation (UAL) was done at the beginning of the procedure. Women were divided into TLH + UAL (n = 30) and TLH (n = 30) groups. In TLH group, TLH was done without ligating the uterine arteries at the beginning of the procedure. In TLH + UAL group, TLH was done with ligation of both uterine arteries at the beginning of the procedure. The mean operating time was longer for the TLH group (99.16 ± 7.01) than TLH + UAL group (63.27 ± 7.16). The median total blood loss was higher in TLH group (109.38 ± 33.03 mL) than TLH + UAL group (47.50 ± 8.12 mL). UAL at the beginning of TLH is a technically feasible procedure. It reduces the total blood loss and decreases the time taken for the procedure and length of hospital stay.

Dedicated orthopedic operating room unit improves operating room efficiency

We investigated the effectiveness of dedicated orthopedic operating rooms (OR) on minimizing time spent on perioperative processes to increase OR throughput in total knee and hip arthroplasty procedures. The use of a dedicated orthopedic unit that included 6 ORs with staff allocated only for those ORs was compared to the use of a traditional staffing model. After matching to simulate randomization, each group consisted of 422 procedures. The dedicated orthopedic unit improved average anesthesia controlled time by 4 minutes (P<.001), operative time by 7 minutes (P=.004) and turnover time by 8 minutes (P<.001). An overall improvement of 19 minutes per procedure using the dedicated unit was observed. Utilizing a dedicated orthopedic unit can save time without increasing adverse events.