Average Operating Room Time Research Articles

Clinical outcomes for minimally invasive sacroiliac joint fusion with allograft using a posterior approach.

Sacroiliac joint (SIJ) dysfunction can occur as a result of injury, degeneration, or inflammation. This dysfunction presents symptoms of pain at various locations, including the low back, hips, buttocks, and legs. The diagnosis of SIJ dysfunction is challenging and cannot be achieved solely with imaging studies such as X-rays, MRI, or CT. The current gold standard diagnostic modality is intra-articular SIJ blocks using two differing local anesthetics. Current treatments for SIJ dysfunction may be beneficial for short-term relief but lack long-term efficacy. The purpose of our study was to examine the outcomes of patients who underwent minimally invasive, posterior SIJ fusion using allograft at a single center. This was a retrospective study which received exemption from the WCG IRB. Data regarding preoperative and postoperative pain levels, surgical time, complications, and medication usage were obtained retrospectively from patient electronic medical records and prescription drug monitoring program reports. No mapping was completed prior to the procedure. Pain was assessed with the 11-point (0-10) Visual Analogue Scale (VAS) and medication usage was assessed using Morphine Milligram Equivalents (MME). Patients were included if they had been diagnosed with SIJ dysfunction using two intra-articular diagnostic blocks that resulted in at least an 80% decrease in pain and had failed conservative management. Patients with sacral insufficiency fractures were excluded. VAS scores reduced from 8.26 (SD = 1.09) at baseline to 2.59 (SD = 2.57), 2.55 (SD = 2.56), 2.71 (SD = 2.88), and 2.71 (SD = 2.88) at 3, 6, 9, and 12 months, respectively. MME reduced from 78.21 mg (SD = 51.33) to 58.95 mg (SD = 48.64), 57.61 mg (SD = 47.92), 61.71 mg (SD = 45.64), and 66.29 mg (SD = 51.65) at 3, 6, 9, and 12 months, respectively. All reductions in VAS scores and MME were statistically significant. No adverse events occurred, and the average operating room time was 40.16 min (SD = 6.27). Minimally invasive, posterior SIJ fusion using allograft is a safe and efficacious method for managing SIJ dysfunction.

Single Port Modified Partial Nephrectomy: Novel Simultaneous Access to Peritoneal and Retroperitoneal Partial Nephrectomy, Initial Clinical Experience.

Introduction and Objective: Since its Food and Drug Administration (FDA) approval in 2018, Intuitive Surgical DaVinci single port (SP) robotic platform has been an effectively used technology for multiple urologic procedures. The purpose of this study is to share our early intraoperative and perioperative outcomes and potential benefits for performing a lower anterior access (LAA) incision for SP robot-assisted partial nephrectomy (SP-RAPN). The LAA incision enables performing a trans- or retroperitoneal (RP) approach through the same incision and eases the transition to a RP approach. Methods: This study is a prospective review of 78 SP-RAPN cases between March 2021 and January 2023 by an experienced robotic surgeon. A single 2-3 cm oblique incision parallel to the external oblique muscle, one-third of the distance between the iliac crest and umbilicus, was used to insert the multichannel port to perform the RAPN. We extracted intra- and perioperative data of these patients to share the outcomes of this approach. Results: SP-RAPN was effectively completed in 78 patients (38 females and 40 males) without conversion to open or laparoscopic techniques. The mean age was 61.2 ± 12.1 years. The mean tumor size was 3.0 ± 1.2 cm, 43 were right-sided masses, and 35 were left sided. The R.E.N.A.L Nephrometry score ranged from (4-11) with an average of 7.0 ± 1.9. Average operating room time was 90.5 ± 24.6 minutes, estimated blood loss was 88.3 ± 134 mL, and length of stay of 1.07 ± 0.7 days. Of the 78 cases, 40 required clamping of the renal artery with average warm ischemia time of 19.4 ± 6.7 minutes in patients who underwent clamping. No complications in all of 78 patients. Conclusions: This study demonstrates the feasibility and reproducibility of SP-RAPN using a LAA incision. This incision provides a standardized approach for surgeons to transition to the RP approach using the SP platform.

Thyroidectomy Outcomes in Obese Patients

IntroductionObese patients often have higher complication rates after elective general surgeries; however, few studies have examined the outcomes after thyroidectomy. This study examines whether increased body mass index (BMI) is associated with poor postoperative outcomes after thyroid surgery. MethodsA retrospective review of patients who underwent thyroidectomy from 2015 to 2018 was performed. Demographics, comorbidities, pathology, and extent of resection (total versus hemithyroidectomy) were examined. Patients were classified into BMI groups according to the WHO definitions, and the incidence of surgical outcomes was determined in each group. Surgical outcomes of interest included readmission rates (RRs), length of stay, average operating room time, return to the operating room, hypocalcemia, postop infections, hematomas, and recurrent laryngeal nerve injury. Between-subjects statistics including independent samples t-test, ANOVA, and chi-square analyses were performed. ResultsThere were n = 465 patients included with a mean BMI 32.35 (standard deviation = 8.55) and median BMI 30.78 (Q1 = 26.26, Q3 = 36.73). There were no differences between BMI groups in age, gender, smoking, heart disease. There was a positive association between increased BMI and postoperative infection (P < 0.001), pneumonia (P = 0.018), and surgical site infection (P = 0.04), which were highest for BMI > 40. Increased BMI was associated with a higher 30-d RR (P = 0.008), particularly for BMI >40 versus BMI <40 (6.2% versus 1.05%; P = 0.003). There were no significant differences between surgical outcomes for patients with increased BMI who underwent total thyroidectomy or hemithyroidectomy. ConclusionsExcellent postoperative outcomes were observed in all BMI categories. Higher postoperative infection and 30-d RRs were observed in the morbidly obese. Contrary to previous studies, operating room times were similar regardless of BMI.

Utilization of Single-Incision Laparoscopy in the Management of Ingested Magnets.

Background: A ban on neodymium magnets was lifted by the U.S. Consumer Product Safety Commission in 2016. Pediatric gastroenterologists and surgeons were increasingly tasked with removing these problematic objects. The purpose of this study was to assess the utility of single-incision laparoscopic surgery (SILS) in the management of ingested magnets. Patients and Methods: This is a single-center, retrospective assessment of surgical interventions for ingested magnets. International Classification of Disease, 10th revision codes were used to identify 349 patients ≤21 years of age evaluated for foreign body ingestion over a 4.5-year period. A medical record review helped isolate 29 (8.3%) magnet ingestions, 9 requiring surgical intervention. RedCap was used for analysis. Results: Of 9 surgical patients, 7 underwent SILS intervention by 1 surgeon. Another surgeon performed an open operation, whereas a third performed a multiport operation. Of the 7 SILS cases, 3 were completed without conversion to open. In one of these cases, bowel resection with primary anastomosis was performed. For SILS cases, average operating room time was 109 minutes (38-170 minutes), time to enteral feeds was 23 hours (0.28-79.2 hours), and hospital length of stay (LOS) was 3.8 days (1.96-6.68 days). Thirty-day readmission for SILS was 14.3%. No other complications were observed. Conclusions: SILS has been safely utilized for magnet retrieval. It offers an ability to identify the affected intestinal segment and an opportunity to intervene extracorporeally through an uncapped port. In addition, knowing where matted bowel is located can direct a limited incision during conversion to laparotomy. This may confer benefits of decreased pain, shortened time to enteral feeds, and decreased hospital LOS.

More accurate, unbiased predictions of operating room times increase labor productivity with the same staff scheduling provided allocated hours are increased

BackgroundSuppose that before surgery starts predictions of cases’ operating room (OR) times are biased. Summing among cases in ORs, bias causes over-utilized or under-utilized time, reducing the efficiency of use of OR time and labor productivity. Correcting for such bias requires just arithmetic. We focus on benefits of improving the accuracy of unbiased predictors of OR times. Globally, for small or large surgical suites, can machine learning and other computational (e.g., Markov-Chain Monte-Carlo) methods for predicting OR times increase labor productivity? MethodsDiscrete-event simulations were performed using a realistic but inherently non-explanatory OR model. Then an analytical model of one OR was used with normally distributed times per case. ResultsDiscrete-event simulation results were consistent quantitatively with the several earlier empirical studies. When mean absolute predictive errors of cases’ OR times were decreased while retaining no bias, there was a negligible but significant reduction in productivity. The analytical model showed that there could equally have been negligible but significant increases in productivity. Managers and clinicians should have no expectation that implementing machine learning software to decrease mean absolute predictive errors will increase productivity if without increases to allocated times (i.e., longer durations of the workday into which cases are scheduled). Suppose that allocated times are increased while maintaining the same (longer) staff shift length (e.g., increasing the hours into which cases are scheduled from 10.5 to 11.5 h while staff continue to work 12 h shifts with <10% risk working late). Then, increasing the accuracy of estimates of cases’ OR times can achieve large (≈6%) increases in productivity, but less so (≈4%) for facilities already (appropriately) using case resequencing decisions to increase productivity. ConclusionsEarlier empirical studies of reductions in predictive error have shown small benefit to unbiased estimators because they used current cases and allocated time. Organizations cannot benefit from modern predictive methods unless allocated times are adjusted statistically, differentiated from the longer hours for staff scheduling. Surgical suites in provinces, organizations, etc., with labor contracts based on coverage of allocated hours (e.g., two 4 h sessions) should not expect benefit, from a labor costs perspective, from investing in newer methods for predicting average operating room time.

Sugammadex versus neostigmine for routine reversal of neuromuscular blockade and the effect on perioperative efficiency

Sugammadex produces recovery from neuromuscular blockade more rapidly and reliably than neostigmine. We sought to determine if sugammadex is associated with improved perioperative efficiency when compared to traditional neuromuscular blockade reversal with neostigmine, potentially offsetting the higher medication cost. This retrospective analysis involved patients receiving either neostigmine or sugammadex for reversal of neuromuscular blockade at a single academic tertiary care hospital. The final propensity-matched groups consisted of 4060 in each group (neostigmine or sugammadex). The primary outcome measured was total time in the operating room. Secondary outcomes included specific measures of perioperative efficiency as well as postoperative pulmonary failure. The average operating room time for patients was 169.59 [1.27] minutes for neostigmine and 157.06 [1.33] minutes for sugammadex (P < 0.001). The difference was primarily accounted for by shorter surgical times (121.45 [1.18] vs 109.62 [1.22] minutes, P < 0.011). Sugammadex was also associated with a shorter post-anesthesia care unit length of stay (102.47 [1.04] vs 98.67 [1.02] minutes, P < 0.001). For 8120 patients, sugammadex use was associated with shorter operating room and surgical durations as well as shorter post-anesthesia care unit stay. The favorable pharmacodynamic profile of sugammadex may improve surgical and perioperative efficiency and offset higher medication cost.

Lateral Patient Positioning for Pilon and Trimalleolar Ankle Fractures

Category:Ankle; TraumaIntroduction/Purpose:Preoperative planning for pilon and trimalleolar ankle fractures can be difficult. Due to fracture complexity, staged open reduction and internal fixation (ORIF) is performed, resulting in two surgeries. For other situations, definitive fixation occurs with one surgery. However, patients require both prone and supine positioning in order to address all fracture components. Repositioning, re-prepping and re-draping adds to operating room (OR) time and time under anesthesia, increasing the risk for anesthesia related complications. Additionally, repositioning the patient can potentially increase fluoroscopy time and radiation exposure to the patient. Lateral patient positioning obviates many of these concerns. Our study goal was to assess the safety and effectiveness of lateral positioning for pilon and trimalleolar ankle fracture ORIF compared with patients placed in standard positioning (i.e supine/prone).Methods:This was a retrospective cohort analysis of 41 patients who underwent operative fixation of a pilon or trimalleolar ankle fracture at a single institution level 1 trauma center. This study compared outcome data for those undergoing the procedure in lateral positioning (n=31) vs. standard (prone/supine) positioning (n=10). Exclusion criteria included pregnant women, prisoners, patients with less than 6 weeks of follow-up, previous or bilateral pilon or ankle fracture surgery or patients treated with limited internal fixation and external fixation. Variables collected included patient demographics, time to union, time to weightbearing, complications and any repeat surgeries. Additionally, chart review was performed analyzing OR time, fluoroscopy time and radiation dose to patient.Results:The patients fixed in the lateral position underwent significantly less time in the OR and subsequent time under anesthesia (p= 0.02). The average OR time in the lateral positioning group was 160 minutes (min) (range: 65-234 min). The average OR time in the standard positioning group was 193 minutes (range: 143- 263 min). Fluoroscopy time was less in the lateral group compared with the standard group (1.47 vs 2.09 min), though this was not statistically significant. Mean patient radiation dose was less in the lateral position group, but without statistical significance (3.22 vs 3.66 mGy). Compared with the standard positioning group, the lateral group demonstrated a significantly shorter time to weightbearing both in (avg 7.8 weeks) and out (avg 11.8 weeks) of the walking boot (p= 0.01). There were no significant differences in complications or time to fracture union.Conclusion:Our results demonstrated that patients treated in the lateral position progressed in their weightbearing faster without increased risk of complications or delayed union, compared with the standard positioning group. Additionally, perhaps the most intriguing conclusion from our study was that OR time, and therefore time under anesthesia was significantly improved with lateral positioning. Fluoroscopic time and radiation dose exposure were also found to be less on average in the lateral positioning group. Our study suggests that lateral positioning for ORIF of pilon or trimalleolar fractures may not only improve patient safety but also reliably lead to acceptable patient outcomes.

Robotic Adrenalectomy: A 10-Year Clinical Experience at a Tertiary Medical Center.

Background and Objective:Laparoscopic adrenalectomy is now the preferred approach for most adrenal tumors. As minimally invasive surgery departments gain familiarity with the robotic platform, the safety profiles and efficacy of robotic adrenalectomy has been an area of continued discussion. The objective of this study is to outline our experience with transitioning to the robotic platform and determining the effectiveness and safety of transperitoneal robotic adrenalectomy.Methods:We performed a single-center, retrospective review of 37 patients who underwent transperitoneal robotic adrenalectomy between August 1, 2010 and August 31, 2020. Outcomes included patient morbidity, hospital length of stay, operative time, estimated blood loss, gland volume, pathology, and postoperative complications.Results:Sixty-five percent of the total robotic adrenalectomies were of the left adrenal gland. The average operating room time was 213 minutes. The average gland volume was 71 cm3, estimated blood loss was 74 mL and length of stay was 1.4 days. There were no significant differences in outcomes between the right and left total robotic adrenalectomies. Approximately one-third of our cohort had an adrenal cortical adenoma, while only one patient had adrenal cortical carcinoma. Four patients experienced postoperative complications that resulted in unplanned hospital readmissions and there was one mortality.Conclusions:Although the standard of care for most adrenal tumors is laparoscopic resection, our 10-year experience has shown that robotic adrenalectomy is highly effective and can be a valuable tool in the community and academic setting.

Comparative Analysis of Open Reduction Internal Fixation and Closed Reduction Percutaneous Pinning of Hand Fractures: Single Academic Center Retrospective Review.

The purpose of our study was to compare postoperative outcomes between patients receiving closed reduction percutaneous pinning (CRPP) to open reduction internal fixation (ORIF) following metacarpal and phalanx fractures. A retrospective chart review was performed at a single academic center for all patients suffering a metacarpal or phalanx fracture and receiving either CRPP or ORIF between 2012 and 2018. Patients were divided into fracture mechanism, high-energy mechanism of injury, low-energy mechanism of injury, or unknown, and treatment of fracture with either ORIF or CRPP. High-energy mechanism of injury included gunshot wounds, motor vehicle crash, and blast injuries, whereas low-energy mechanism of injury included all other causes. Patient demographics, postoperative complications, 30-day readmission, and return to the operating room were recorded. A total of 408 patients, with 524 fractures, were included in the study. There were 127 fractures that resulted from high-energy mechanisms and 394 fractures that resulted from low-energy mechanisms. Open reduction internal fixation was used to treat 299 fractures, whereas CRPP was used for 225 fractures. Among fracture fixation, there was a total of 8.4% complication rate with ORIF, accounting for 10.4% of complications, and CRPP accounting for 5.8%. Among the fracture mechanism, the high-energy mechanism of injury had a 21.3% complication rate, whereas the low-energy mechanism of energy was 4.3%. When comparing the above variables, only high-energy mechanism of injury was a statistically significant predictor of complications (odds ratio, 3.2; confidence interval, 1.5-7.0; P = 0.002). The average operating room time for the ORIF group was 124.82 minutes compared with 97.6 minutes for the CRPP group. Patients with hand fractures corrected by ORIF appeared to have a higher postoperative complication rate. When the 2 procedures, ORIF and CRPP, were controlled for mechanism of injury, there was not a statistically significant difference in postoperative complication rate (P = 0.14). However, a fracture sustained by a high-energy mechanism was a statistically significant predictor of postoperative complications (P = 0.002).

Minimally Invasive Dorsal Cheilectomy and Hallux Metatarsal Phalangeal Joint Arthroscopy for the Treatment of Hallux Rigidus.

Background:Hallux rigidus (HR) is a common source of forefoot pain and disability. For those who fail nonoperative treatment, minimally invasive dorsal cheilectomy (MIDC) is an increasingly popular alternative to the open approach with early positive results. Early failures may be due to lose bone debris from the MIDC as well as other intra-articular pathology that cannot be addressed with MIDC alone. Metatarsophalangeal (MTP) arthroscopy can be used in addition to MIDC to assess the joint after MIDC and address any intra-articular pathology while still maintaining the benefits of minimally invasive surgery. We report our clinical outcomes following MIDC combined with MTP arthroscopy.Methods:From November 2017 to July 2020, a retrospective analysis of all MIDC cheilectomies with MTP arthroscopy performed by the 2 senior authors was done. Wound complications, infections, revision rates, need for future surgery, conversion to fusion rates, pre- and postoperative range of motion, visual analog scale (VAS) scores, time to return to normal shoe, intraoperative arthroscopic findings, and operative time were collected. Follow-up average was 16.5 months (range 3-33 months).Results:A total of 20 patients were included with an average follow-up of 16.5 months. The average VAS score improved from 7.05 preoperatively to 0.75 postoperatively (P < .05). Average range of motion in dorsiflexion increased from 32 to 48 degrees (P < .05) and plantarflexion increased from 15 to 19 degrees plantarflexion (P < .05). All patients were weightbearing as tolerated immediately after surgery in a postoperative shoe and transitioned to a regular shoe at average of 2.1 weeks. We had no wound infections, wound complications, revision surgeries, tendon injuries or nerve damage. One patient required conversion to a fusion 3 years after the index procedure. Average tourniquet time was 30.39 minutes (range 17-60 minutes) and total average operating room time was 59.7 minutes (range 40-87 minutes). On arthroscopic evaluation of the MTP joint after MIDC, 100% of patients had bone debris, 100% had synovitis, 10% had loose bodies, and 30% had large cartilage flaps within the joint.Conclusion:MIDC and first MTP joint arthroscopy for treatment of hallux rigidus provide improved pain relief with minimal complications while still maintaining the benefits touted for minimally invasive operative procedures. Additionally, we have shown a high rate of intra-articular debris along with intra-articular pathology such as synovitis, loose chondral flaps, and loose bodies that exist after MIDC. This combined procedure has the potential for improving patient outcomes and may minimize risk of future revision surgeries compared with MIDC alone.Level of Evidence:Level IV, case series study.

Complications and readmissions following reverse total shoulder arthroplasty with same-day discharge

Background: Recent studies have demonstrated the safety of anatomic total shoulder arthroplasty (TSA) in an outpatient setting. No clinical studies to date have specifically analyzed complication and readmission rates following RTSA with same-day discharge. The purpose of this study was to compare the 90-day complication and readmission rates of patients undergoing reverse total shoulder arthroplasty (RTSA) who were discharged to home on the same day with those of patients who were admitted to the inpatient setting for at least one night.Methods: 135 consecutive patients who underwent 144 RTSA between were analyzed. Suitability for same-day discharge was determined preoperatively using standardized criteria. Operative time, 90-day readmission and complication rates, as well as ASA class and Charlson Comorbidity Index scores were recorded and compared between groups. Differences between the patients undergoing inpatient RTSA (Group 1) versus RTSA with same-day discharge (Group 2) were evaluated with student's t-test, Mann–Whitney, or Chi square as statistically appropriate, and reported as p-values.Results: Group 1 was significantly older than Group 2 when analyzed as a whole (74.3 years vs. 67.5 years, p < 0.001) and when stratified by ASA score. Group 1 had significantly higher ASA and CCI scores than Group 2 (p < 0.001). Average total operating room (OR) time was significantly longer in Group 1 than Group 2 (183 ± 45 min versus 153 ± 30 min, respectively; p < 0.001). There were 7 postoperative complications (7.6%) in Group 1 (2 postoperative seromas, 1 stress fracture, 1 dissociation of prosthesis, 1 brachial plexopathy, 1 episode of syncope, and 1 C acnes reinfection) within the 90-day postoperative period. There were 4 postoperative complications (7.7%) in Group 2 (2 postoperative seromas, 1 periprosthetic fracture, and 1 dislocation). One patient (1.1%) in Group 1 (C. Acnes infection) and 1 patient (1.9%) in Group 2 (periprosthetic fracture) required readmission within 90 days. There were no significant differences in postoperative complications or readmissions between the groups.Conclusion: RTSA with same-day discharge is a safe option for appropriately selected patients. Same-day discharge does not increase 90-day readmission and complication rates following RTSA.Level of Evidence: Level III

Cost Analysis for In-house versus Industry-printed Skull Models for Acute Midfacial Fractures.

Background:Industry-printed (IP) 3-dimensional (3D) models are commonly used for secondary midfacial reconstructive cases but not for acute cases due to their high cost and long turnaround time. We have begun using in-house (IH) printed models for complex unilateral midface trauma. We hypothesized that IH models would decrease cost and turnaround time, compared with IP models.Methods:We retrospectively examined cost and turnaround time data from midface trauma cases performed in 2017–2019 using 3D models (total, n = 15; IH, n = 10; IP, n = 5). Data for IH models were obtained through itemized cost reports from our Biomedical Engineering Department, where the models were printed. Data associated with IP models were obtained through itemized cost reports from our industry vendor. Perioperative data were collected from electronic medical records.Results:The average cost for IH models ($236.38 ± 26.17) was significantly less (P < 0.001) than that for IP models ($1677.82 ± 488.43). Minimal possible time from planning to model delivery was determined. IH models could be produced in as little as 4.65 hours, whereas the IP models required a minimum of 5 days (120 hours) from order placement. There were no significant differences in average operating room time (P = 0.34), surgical complications, or subjective outcomes, but there was a significant difference in estimated blood loss (P = 0.04).Conclusion:Utilization of IH 3D skull models is a creative and practical adjunct to complex unilateral midfacial trauma that also reduces cost and turnaround time compared with IP 3D models.

Is Time of the Essence: A Retrospective Analysis of Operating Room Procedure Length for First Phase Damage Control Trauma Surgery

Background:The concept of Damage Control Surgery (DCS) consists of a truncated surgical intervention with main focus on hemorrhage and contamination control. Traditionally,DCS involves limiting operating room (OR) time for patients with multiple life-threatening injuries and coagulopathy who are reaching physiologic exhaustion. However, in the modern era of hemostatic resuscitation, there is a paucity of evidence to support a survival benefit with shorter OR times. The objective of this study was to determine the practice habits of trauma surgeons in the modern era of DCS and to determine if operation length affects mortality in trauma patients with abdominal injuries.&#x0D; Methods:An 8-year retrospective review of consecutive adult patients with DCSfor penetrating abdominal trauma at a Level I trauma center was conducted. Patient demographics, injury severity score (ISS), and penetrating abdominal trauma index (PATI) scores were obtained. Average operating room times for initial DCS were determined. Patient outcomes were analyzed with a t-test for univariate analysis and a Cox proportional hazard ratio modeling was used to predict factors for survival. &#x0D; Results:A total of 193 patients were included in the study. The overall patient mortality was 14.0% (n=27/193). Median OR time was 157 minutes (range, 59-573 min). Patients were stratified into short OR group (SHORT, n=95) and long OR group (LORT, n=98) based on the median operative time. Only one patient had an initial DCL less than 60 minutes. The SHORT group received more blood transfusions (52.6% vs. 35.7%, p=0.02) in the ICU. Average operative room time was almost twice as long in the LORT group (214.6+6.2 vs. 121.4+2.6 minutes, p&lt;0.0001). The average hospital length of stay (22.8+2.3 vs. 31.0+3.5 days, p=0.05) and ICU length of stay (10.6+1.2 vs. 12.6+1.4 days, p=0.28) were both lower in the LORT group compared to the SHORT group. The SHORT group had 22 patients with unplanned return to the OR compared to 3 in the LORT group (p&lt;0.0001). On multivariate analysis, OR time was not an independent risk factor for mortality (OR 1.0, 95% CI 0.98-1.0, p=0.48).&#x0D; Conclusions: Modern damage control practices should focus on early and effective surgical hemorrhage control in combination with effective intra-op hemostatic resuscitation efforts and not on how time limitations. These findings suggest that OR time restrictions in the era of effective hemostatic resuscitation in combination with DCS does not impact mortality.

Global hospital and operative costs associated with various ventral cavity procedures: a comprehensive literature review and analysis across regions

Objectives: The aim of this literature review was to provide a comprehensive report on hospital costs, and cost components, for a range of ventral cavity surgical procedures across three regions of focus: (1) Americas, (2) Europe, Middle East and Africa (EMEA), and (3) Asia-Pacific.Methods: A structured search was performed and utilized a combination of controlled vocabulary (e.g., “Hepatectomy”, “Colectomy”, “Costs and Cost Analysis”) and keywords (e.g. “liver resection”, “bowel removal”, “economics”). Studies were considered eligible for inclusion if they reported hospital-related costs associated with the procedures of interest. Cost outcomes included operating room (OR) time costs, total OR costs, ward stay costs, total admission costs, OR cost per minute and ward cost per day. All costs were converted to 2018 USD.Results: Total admission costs were observed to be highest in the Americas, with an average cost of $15,791. The average OR time cost per minute was found to vary by region: $24.83 (Americas), $14.29 (Asia-Pacific), and $13.90 (EMEA). A cost-breakdown demonstrated that OR costs typically comprised close to 50%, or more, of hospital admission costs. This review also demonstrates that decreasing OR time by 30 min provides cost savings approximately equivalent to a 1-day reduction in ward time.Conclusion: This literature review provided a comprehensive assessment of hospital costs across various surgical procedures, approaches, and geographical regions. Our findings indicate that novel processes and healthcare technologies that aim to reduce resources such as operating time and hospital stay, can potentially provide resource savings for hospital payers.

Minimally Invasive Approach for Resection of Masseteric Vascular Malformations.

Vascular malformations (VMs) in the head and neck region often cause esthetic as well as functional problems for patients. Intramuscular VMs (IVM), such as those in the masseter, can cause severe facial asymmetry and typically are excised transcutaneously to facilitate wide exposure and safe dissection from the facial nerve. This requires extensive dissection, prolonged healing, and can lead to suboptimal facial scarring. We describe the technique of resecting large IVMs of the masseter muscle in 3 patients using an entirely intraoral approach with continuous nerve monitoring and without visible facial scarring or secondary deformity. Preoperative injection of sclerotherapy was performed to reduce intra-operative bleeding and optimize resection. Successful excision was performed without complication in 3 patients to date. Total average operating room time was 120 minutes (range 95-145 minutes). Estimated blood loss was 213 mL (range 180-240 mL). The patients were discharged home either post-operative day (POD) 1 or 2, with 1 returning to work POD 4. Facial nerve function was normal postoperatively and no hematomas developed. Subjective masticatory function was equivalent to preoperative levels in all patients. Intraoral excision of VMs of the masseter muscle can be safely performed without added risk or complication. Continuous facial nerve monitoring allows minimally invasive approaches to be considered with less risk of iatrogenic facial nerve injury. We purport that this is a safe and effective method with substantially better esthetic outcomes compared with traditional transcutaneous approaches.

Lower Extremity Limb Salvage with Cross Leg Pedicle Flap, Cross Leg Free Flap, and Cross Leg Vascular Cable Bridge Flap.

Lower extremity salvage following significant soft tissue loss can be complicated by lack of recipient vessel for free tissue transfer. We describe our experience in lower limb salvage for patients with no recipient vessels with the use of pedicle, free and cable bridge flaps. A retrospective review from 1985 to 2017 of patients undergoing lower limb salvage using a contralateral pedicle cross leg (PCL) flaps, free cross leg (FCL) flaps, or free cable bridge (FCB) flaps was conducted. Demographics, etiology of the reconstruction, type of flap used, donor-site vessels, defect size, operating time, time of pedicle division, length of hospital stay, time to ambulation, and complications were analyzed. A total of 53 patients (48 males and 5 females) with an average age of 35 years (range, 29-38 years) were identified. The etiology for the reconstruction was trauma in 52 patients and oncological resection in 1 patient. There were 18 PCL, 25 FCL, and 10 FCB completed. The recipient vessels for all flaps were the posterior tibial artery and vein. The average operating room times for PCL, FCL, and FCB flaps were 4, 9, and 10 hours, respectively. The average length of hospital stay was 5 weeks and average time to ambulation was 4 weeks. The average follow-up time was 7.5 years (range, 3-12 years). Complications encountered were hematoma (six), prolonged pain (six), total flap loss (two), reoperation (five), and infection (four). Limb salvage rates were 96.2%. When ipsilateral limb vessels are not available, and other reconstructive options have been exhausted, cross leg flaps can be a viable option for limb salvage in the setting of extensive defects.

A Retrospective Study: Performing Opportunistic Salpingectomy at Time of Cesarean at a Community Residency Program [21B

INTRODUCTION: The American College of Obstetricians and Gynecologists (ACOG) supports discussing opportunistic salpingectomy at the time of pre-operative counseling period for benign gynecologic surgery. Cesarean section is the most common procedure an obstetrician-gynecologist performs in the United States; however, little data exists regarding performing opportunistic salpingectomies at the time of cesarean delivery. This retrospective study sought to evaluate the safety of performing an opportunistic salpingectomy at the time of cesarean section. METHODS: A total of 56 patients with singleton intrauterine pregnancy &gt;37 weeks gestational age undergoing a scheduled cesarean at St. Vincent Women’s Hospital were identified from January 1, 2015 to August 1, 2017. Data was abstracted from electronic medical records. Estimated blood loss (EBL), length of operating room (OR) time, differences in hemoglobin pre and post-operatively, and return to operating room within 30 days were analyzed. Other data abstracted included age, body mass index, gravidity/parity, pregnancy complications (e.g., diabetes), training level of surgeon, and surgical technique. RESULTS: The average drop in hemoglobin was 1.25 g/dL. Average EBL was 745cc. The most common method was using a Ligasure device, followed by traditional clamp, cut, and tie. One patient required transfusion postoperatively for hemoglobin of 6.7 g/dL. Average OR time was 99.5 minutes. No patients returned to the OR for complications related to surgery. CONCLUSION: Performing bilateral salpingectomy at the time of cesarean section appears to be safe. Physicians performing cesarean sections should offer opportunistic salpingectomies to women at average-risk for developing ovarian cancer.

Surgical Results of Common Peroneal Nerve Neuroplasty at Lateral Fibular Neck.

Common peroneal nerve (CPN) compressive neuropathy is the most common lower-extremity entrapment neuropathy. A retrospective review of a prospectively maintained single-institution database of all patients with CPN palsy who underwent decompression and neuroplasty over a 5-year period was performed. Thirty patients underwent a neuroplasty of the CPN over a 5-year period (2010-2015) at our institution. The median age was 45 years, and there was a male preponderance. The average time between first onset of symptoms to surgery was 122.9 weeks and between first clinic visit and surgery was 21 weeks. The etiology of the CPN neuropathy was as follows: in 12 patients, it followed a surgical procedure and in 14 patients, it occurred after a trauma to the lower extremity. In 2 patients, it occurred as a result of a mass lesion compromising the nerve and in 1 patient, a local infection predisposed to CPN palsy. Right and left lower extremities were equally involved. The median body mass index was 28.6. The most common presentation was weakness of the tibialis anterior (TA) and extensor hallucis longus (EHL) and loss of sensation in the distribution of the CPN or one of its major branches. Pain was a presenting symptom in 16 patients. Only 12 of the 30 patients had a positive Tinel's sign at the site of compression over the lateral fibular neck. Preoperative electrophysiologic confirmation of CPN neuropathy was available in all patients. Mean follow-up was 52 weeks. Prone positioning and selective use of the operating microscope provided excellent visualization and surgical exposure of the CPN from the lower popliteal region to the peroneal tunnel. Average operating room time was 170 minutes and average skin-to-skin time 91 minutes. Clinical improvement after surgery in terms of motor function was noted in 24 of the 26 patients who presented with a motor deficit. The most consistent improvement was noted in the TA and EHL; a trend toward greater improvement with shorter time to surgery was noted. No complications related to the surgical site or CPN were encountered, and no patient had a decline in their neurologic examination as a consequence of the surgery. One patient developed a positioning-related right upper-extremity brachial plexus neuropraxic injury after surgery that recovered completely. Common peroneal neuropathy usually presents with weakness of the TA and EHL and decreased sensation or pain in the distribution of the CPN. Microscope-assisted surgical neuroplasty of the CPN at the lateral fibular neck with the patient in a prone position allows decompression of the nerve from the lower popliteal region to the peroneal tunnel. Significant improvement in motor strength after surgery, particularly of the TA and EHL, was observed in this series.

Acute and Hyper-acute Thoracolumbar Corpectomy for Traumatic Burst Fractures Using a Mini-open Lateral Approach

Retrospective chart review. The purpose of this study was to examine the feasibility of acute (<24 hours) and hyperacute (<8 hours) treatment of thoracolumbar burst fractures to maintain or improve spinal injury scores. Historically, treatment of spinal burst fractures within 24 hours from injury was considered an "acute" treatment timeframe. Patient polytrauma triage, multiple surgical specialty, and hospital resource coordination affect time to treatment. The mini-open lateral approach for thoracolumbar corpectomy obviates the need for an approach surgeon, which may allow for early surgical intervention. Sixteen patients treated within 24 hours with a mini-open lateral corpectomy for traumatic spinal pathology were reviewed for preoperative, perioperative, and postoperative data. Neurologic status was assessed using American Spinal Injury Association (ASIA) scores. Fractures occurred primarily from L1 to L3. Wide-footprint expandable titanium devices were used in 75% of patients. All patients received supplemental fixation. Average time from injury to admission to the hospital (emergency room [ER]) was 1.8 hours, with an average time from the ER to operating room (OR) of 8.2 hours and an average OR time of 2.7 hours. Eight patients required ≤8 hours from injury event to surgical initiation, whereas seven patients required between 8 and 24 hours for surgery initiation (one patient with incomplete surgical timing record). Blood loss averaged 646 mL without intraoperative complication. One perioperative complication occurred and one patient developed an asymptomatic inferior vertebral body fracture. Length of hospital stay averaged 6 days. At last follow-up, nearly all patients experienced full or near-complete neurologic recovery with at least one ASIA grade improvement seen in 73% and 20% of patients improving two grades or more. These results suggest that mini-open lateral approaches allow immediate decompression through hyperacute (<8 hours) treatment of spinal burst fractures in eligible patients. Additionally, low perioperative and postoperative morbidity allows for hastened recovery. 4.

PP151 Comparison Of Patients Undergoing New Technology For Prostate Cancer

Introduction:Prostate neoplasia affects more than one million people worldwide. Surgical treatments have evolved from open or video prostatectomy, up to the High Intensity Focused Ultrasound (HIFU) technique. HIFU studies cite less costs and better quality of life during the first year of follow-up. The objective of this study is to describe a consecutive series of eligible patients, with Gleason score 6 and 7, and compare resources used along those three treatment techniques.Methods:A comparative and retrospective study was conducted during the first 2017 semester, at Hospital de Transplantes de São Paulo, São Paulo city, Brazil. Consecutive eligible patients were matched by age, disease stage and profile and Gleason score 6 or 7. Resources used were assessed through medical records review and in- and out-patient visit interviews.Results:A total of 152 patients were followed: 50 underwent open surgery prostatectomy, 50 underwent video prostatectomy and 52 underwent HIFU. Mean age did not differ between groups (66.6, 64.1 and 65.6 years, respectively). All patients were followed for at least three months. The average operating room time was 4.7, 4.1 and 2.3 hours, and the average anesthetic recovery time was 2.0, 1.9 and 2.0 hours, respectively. Average inpatient length of stay was 2.5, 2.7 and 1.5 days, respectively. Postoperatively, nine (18 percent) open surgery patients, and 14 (28 percent) video-prostatectomy patients required an average of one full day of intensive care, compared to only one (2 percent) HIFU patient. During follow-up, the same effectiveness was observed between the groups, none required re-intervention. Thus, considering the 50 percent economy in hours of operating room and of days of hospital stay, as well as 10 times less use of intensive care unit days when the HIFU technique was compared to conventional surgeries, it is estimated the HIFU program allowed 30 percent cost savings.Conclusions:The HIFU program presented effectiveness and savings. The hospital can increase access to care for prostate neoplasia patients.