Overlapping Foot and Ankle Surgery

Abstract

Overlapping surgery involves a single surgeon running 2 operating rooms on a staggered schedule such that the surgical care of the patients involved partly coincides in time. Some portions of a surgical case are more difficult and require the direct, hands-on attention of the attending surgeon. These are considered critical portions of a surgical case. However, other elements of a surgical case are less technically involved and are considered noncritical. For the noncritical portions of an operation, the attending surgeon can leave 1 operating room and conduct the more technically demanding portions of another case underway in an adjacent operating room, without compromising the care of the patients involved. Thus, patients can receive optimal care, the hospital more efficiently allocates its resources, and surgeons-in-training benefit from both skilled supervision and the opportunity to think for themselves. Technically, overlapping surgery is not the same as concurrent surgery, according to the American College of Surgeons (1Hoyt D.B. Angelos P. Concurrent surgery: what is appropriate?.Adv Surg. 2017; 51: 113-124Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar). In concurrent (simultaneous) operations, critical elements for which the attending surgeon is responsible occur all, or in part, at the same time, and such practice is, as a rule, unethical. Overlapping operations, in contrast, stagger the start of each case such that the attending surgeon can be present for the execution of the critical elements of each operation. The U.S. Centers for Medicare and Medicaid Services has stated that, for a surgeon to bill Medicare for 2 overlapping surgeries, the teaching surgeon must be present during the critical or key portions of both operations; therefore, the critical or key portions must not occur at the same time (2CMS Manual System, Department of Health & Human Services (DHHS) Pub 100-04 Medicare Claims Processing, Centers for Medicare & Medicaid Services (CMS), Transmittal 2303.2011Google Scholar). Moreover, evidence-based assessments of the results of overlapping surgeries have shown that the practice is safe and effective and does not compromise outcomes (1Hoyt D.B. Angelos P. Concurrent surgery: what is appropriate?.Adv Surg. 2017; 51: 113-124Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 3Mello M.M. Livingston E.H. Managing the risks of concurrent surgeries.JAMA. 2016; 315: 1563-1564Crossref PubMed Scopus (47) Google Scholar, 4Hyder J.A. Hanson K.T. Storlie C.B. Glasgow A. Madde N.R. Brown M.J. Kor D.J. Cima R.R. Habermann E.B. Safety of overlapping surgery at a high volume referral center.Ann Surg. 2017; 265: 639-644Crossref PubMed Scopus (58) Google Scholar). The practice of overlapping surgery is common in many hospitals, especially at teaching hospitals. In these hospitals, the hierarchy of fellowship and resident surgeons provides a system in which surgeons-in-training have extensive experience exposing target structures and closing surgical wounds, because they have performed such maneuvers many times (sometimes hundreds of times) during their years of training. Also, as Michael S. Pinzur, MD, stated in his recent commentary, in addition to supervision, resident and fellow surgeons “also require some degree of autonomy so they will be able to develop the judgment and skills necessary to perform surgery” (5Pinzur M.S. FootForum: concurrent surgery.Foot Ankle Int. 2017; 38: 1289-1290Crossref PubMed Scopus (2) Google Scholar). The attending surgeon's decision to conduct overlapping cases hinges on a number of variables. These include the specific medical and surgical needs of each patient, the level of assistant surgeon training and skill available, the trust between the attending surgeon and the fellows and/or residents providing the assistance, the proximity of the operating rooms used to conduct the concurrent operations, and communication between the anesthesia team and the operating room staff with the surgeon. In addition, effective communication between the attending surgeon and the patients involved is necessary, because the patients must be aware of, and consent to, the plan and practice. The plan to perform, or the possibility of performing, overlapping surgical cases warrants discussion with the patient when the surgery is planned and documentation of the plan during the ongoing informed consent process. Foot and ankle surgeons who perform overlapping surgeries, and who train residents and fellows, are encouraged to further investigate this subject in the surgical literature.