Lead Surgeons Research Articles

Ovarian Tissue Collection for Fertility Preservation in Children: The Need for Standardised Surgical Practice Guidance

BackgroundChemotherapy, pelvic radiotherapy (including total body irradiation) and novel compounds used to treat children and teenagers with benign or malignant diseases can lead to impaired fertility. For prepubertal female patients at high risk of treatment-related infertility, upfront storage of ovarian tissue is increasingly being recognised as standard of care. No surgical guidelines exist to ensure best practice technique. We reviewed current UK practice to assess surgical management. MethodsA ten-item, anonymous multiple-choice survey was distributed to the lead surgeons in all paediatric centres in England/Wales undertaking ovarian procurement for cryopreservation. ResultsThere are currently 18 centres in England and Wales that provide ovarian procurement for cryopreservation. Responses were received from 100% of the invited paediatric surgical oncology centres in England and Wales.39.3% of participants stated that in their centre <10 cases of ovarian harvest are performed annually. In 32.1% of centres >20 cases are undertaken per year.In 64% of centres surgery is performed by a paediatric surgeon with interest in oncology or fertility preservation. The majority of cases were performed by a Consultant or Senior Registrar (89%).Regarding the surgical technique, 82% of respondents stated they gain access to the abdominal cavity using standard 3-port laparoscopy, 7% use single-port laparoscopy. Most frequently used energy devices for ovary/ovarian tissue resection were Ligasure™ (44%) and Harmonic Scalpel™ (18.5%). 96% of respondents perform a total oophorectomy, 1 respondent stated they perform a hemi-oophorectomy. 53% stated they place the ovary into a retrieval bag only if the ovary was too big for easy removal via the camera port, 28.5% always place it in a retrieval bag. Most surgeons use the umbilical port site for retrieval (82%). ConclusionThis national survey shows significant heterogeneity in the surgical management of ovarian procurement for cryopreservation. To ensure best outcomes, research into the various surgical methods is necessary to provide data for a standardised best practice approach. Level of EvidenceThis is a level II evidence study. In itself, it is a national survey of specialists, which was undertaken in a prospective manner.

Factors impacting neurosurgery residents' operative case volume: a nationwide survey.

Neurological surgery residency remains one of the most competitive and longest specialties in terms of training in medicine. The Accreditation Council for Graduate Medical Education uses residents' case volume throughout residency as one of its measures for the quality of surgical training. The objective was to study the variability of residency case volume among US training programs and to analyze the factors that potentially influence that case volume. In line with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines, an online survey regarding department size, case volume, number of residents per year, number of dedicated research years, presence of fellows, and resident case volume by the time of graduation was created using Google Forms and distributed to all neurosurgery residency program directors and coordinators in the US. A total of 97 of the 115 programs (84.3%) responded to the survey. Fifteen programs were excluded due to missing data or incomplete resident cohort at the time of the survey, and a total of 82 programs were included in the analysis. The average number of cases performed by residents as lead or senior surgeons by the time of graduation ranged from 900 to 2250 (median 1600 cases). The resident case volume did not have a significant correlation with the program case volume, number of operating attending neurosurgeons, number of residents, number of research years, or presence of fellows. The only factor that impacted the resident case volume was the number of cases performed per faculty. The number of cases performed by residents throughout residency varied significantly between programs. Although other factors play important roles in the quality of training, including autonomy, variation, and complexity of cases, the resident case volume is one of the only measurable factors. This study sheds some light on the factors that potentially influence neurosurgical resident case volume.

Surgeon fatigue in robot-assisted and laparoscopic gastrectomy for gastric cancer: Exploratory prospective observational study ancillary to JCOG1907 randomized controlled trial (JCOG1907A1).

TPS422 Background: Fatigue is being increasingly recognized as an important factor in surgical procedures, because it leads to errors in surgeons' decisions and reduced operating efficiency. In comparison to laparoscopic surgery, robot-assisted surgery is expected to reduce surgeon fatigue due to ergonomic adjustments, comfortable sitting positions, minimal restriction of instrument movement, and stable visualization. The aim of this study is to assess surgeon fatigue and explore the superiority of robot-assisted gastrectomy over laparoscopic gastrectomy in surgeon fatigue. Methods: This study is conducted as a prospective observational study ancillary to a randomized controlled phase III trial investigating the superiority in safety of robot-assisted gastrectomy over laparoscopic gastrectomy for clinical stage T1-4aN0-3 gastric cancer (JCOG1907: UMIN000039825). The lead surgeon and the first assistant performing surgeries as protocol treatment in JCOG1907 were included. Surgeon fatigue is quantitatively assessed using multiple assessment tools. The primary endpoint is the average NASA-Task Load Index (NASA-TLX) value for the lead surgeons. Secondary endpoints include six individual parameters of NASA-TLX, visual analog scale assessments for fatigue, advanced trail-making tests, and continuous heart rate variability measurements for lead surgeons and first assistants. The primary analysis compares surgeon fatigue between robot-assisted and laparoscopic surgery. Secondary analyses examine the association between surgeon fatigue and various factors, such as surgeon and patient background, and surgical findings, as well as cross-correlations among measures of surgical fatigue. In addition, the association between surgeon fatigue and postoperative complications and its impact on long-term survival outcomes is also evaluated. The sample size is 500 surgical cases, with a planned accrual period of 2 years. This study was initiated in April 2023 and registered at the University Hospital Medical Information Network as UMIN000052120. As of August 2023, 52 cases (10.4% of the planned accrual) have been enrolled in the study. Clinical trial information: UMIN000052120 .

Benefits and limitations of a dual faculty neurosurgeon approach to resection of pediatric craniopharyngioma.

The utility and safety of including two neurosurgeons for tumor resections is unknown. This study compares outcomes among pediatric patients with craniopharyngiomas operated on with a dual or single surgeon approach (DSA, SSA). A single-center review identified all craniopharyngioma transsphenoidal or craniotomy resections from 2000 to 2020. Surgical years of experience (YOE) and rates of 5-year reoperations, complications, recurrence, and postoperative radiotherapy were analyzed. Twenty-six transsphenoidal and 68 craniotomies were identified among 62 patients. Eleven transsphenoidal (42.3%) utilized DSA and 15 utilized (57.7%) SSA. Eight craniotomies (11.8%) were DSA and 60 (88.2%) were SSA.The surgeon for SSA transsphenoidal procedures had a median of 10.7 YOE (IQR: 9.9-13.7) versus 6.6 (IQR: 2.7-16; p = 0.058) for the lead surgeon in DSAs. The co-surgeon in transsphenoidal DSAs had a median of 27 YOE (IQR: 11.8-35.7).The surgeon for SSA craniotomies had a median of 19.3 YOE (IQR: 12.1-26.4) versus 4.5years (IQR: 1.3-15.3; p = 0.017) for the lead surgeon in DSA cases. The co-surgeon in DSA craniotomies had a median of 23.2 YOE (IQR: 12.6-31.4).Case complexity was similar across transsphenoidal groups. DSA transsphenoidal resections had fewer complications (18% DSA vs. 33% SSA), reoperations (45% vs. 53%), and radiation therapy (9.1% DSA vs. 33% SSA) than SSA. Lead surgeons in DSAs are frequently junior surgeons while SSAs typically employ senior surgeons. Outcomes did not significantly differ between DSA and SSA. Mentorship through DSAs does not negatively affect patient care.

Unmasking bias and perception of lead surgeons in the operating room: A simulation based study

BackgroundPerception of a surgeon based on physical attributes in the operating room (OR) environment has not been assessed, which was our primary goal. MethodsA common OR scenario was simulated using 8 different actors as a lead surgeon with combinations of age (<40 vs. >55), race (white vs. black), and gender (male vs. female). One video scenario with a survey was electronically distributed to surgeons, residents, and OR nurses/staff. The overall rating, assessment, and perception of the lead surgeon were assessed. ResultsOf 974 respondents, 64.5% were females. There were significant differences in the rating and assessment based upon surgeon's age (p = .01) favoring older surgeons. There were significant differences in the assessments of surgeons by the study group (p = .03). The positive assessments as well as perceptions trended highest towards male, older, and white surgeons, especially in the stressful situation. ConclusionWhile perception of gender bias may be widespread, age and race biases may also play a role in the OR. Inter-professional education training for OR teams could be developed to help alleviate such biases.

621 Impact Of COVID-19 On Surgical Training at A District General Hospital in London

IntroductionCOVID 19 affected surgical training owing to changes in rotations, moving trusts/departments, surgical skills acquisition and new guidelines/protocols during unprecedented times. Aim was to infer how redeployment impacted surgical skills via an objective and subjective study.MethodA retrospective observational study comparing lead surgeons in Laparotomy and Appendectomies between 23rd March- 31st July (2019/2020). A subjective survey was done to elucidate perspectives on skill, academic advancement and trust/deanery support. A focussed group discussion was also done to gain insight on physical and psychological well-being.ResultsLaparotomy 2019 (n = 75) had 59%; 41%; 0% - Consultants/Registrars/ fellows respectively as lead surgeons. 2020 Laparotomies (n = 50) had 40% consultants; 41% registrars; 20% fellowsSimilarly, Appendectomy 2019 (n = 94) had 8.5% consultants; 71.3% registrars; 3.2% clinical fellows, whereas 2020 Appendectomies (n = 67) had 18% consultants; 71.6% registrars and 10.4% fellows.The Likert questionnaire showed 42.86% had mental exhaustion, less confidence/skills due to lesser opportunities/procedures. 57.14% expressed COVID 19 extremely affected surgical training while 28.14% believed in a reduction of 81-100% operative log book entries from before.ConclusionsAlthough, the results were not significant in number of cases managed by trainees; many reported perceived loss of training( log book/portfolio), less teaching/training opportunities and mental exhaustion.

Longitudinal Survey of Trainee Case Log Entry for Carotid Endarterectomy: Trends in Neurological, General and Vascular Surgery

Multiple surgical specialties perform carotid endarterectomy (CEA). As indications for CEA narrows, neurosurgery residents are less exposed to this procedure. This study aims to determine trends in CEA training among graduating trainees in neurosurgery and compare these to general and vascular surgery. ACGME case log reports were retrospectively reviewed from 2013 to 2019 for neurologic, general, and vascular surgery residencies and vascular surgery fellowship. These annual reports contain the mean number of logged cases for graduating trainees and their level of participation. We analyzed trends in logged cases over the study period and compared mean number of logged cases between specialties and their respective required minimum numbers. Neurosurgery residents (13.5 ± 0.76) performed significantly more CEAs than their counterparts in general surgery (9.4 ± 0.34, P < 0.01) but less in integrated vascular surgery (57.7 ± 0.88) and vascular surgery fellowship (47.9 ± 0.79, both P < 0.001). The only statistically significant change over the study period was a decline in mean number of cases logged by general surgery residents at-0.4 cases/year (P < 0.001). Trainees in all specialties reported around twice as many cases as the respective Accreditation Council for Graduate Medical Education required minimum numbers. Neurosurgery residents demonstrated increasing participation as lead surgeons by 0.7 cases/year (P= 0.04) and a concurrent decline as senior surgeons by 1.4 cases/year (P < 0.01). Neurosurgery residents exceeded their minimum requirements for CEA, with increasing trend in higher level of participation. But neurosurgery residents' exposure to this procedure was far less significant than their colleagues in vascular surgery, a gap that may widen over time and should be addressed proactively.

Predictive Model for Selection of Upper Treated Vertebra Using a Machine Learning Approach

To train and validate an algorithm mimicking decision making of experienced surgeons regarding upper instrumented vertebra (UIV) selection in surgical correction of thoracolumbar adult spinal deformity. A retrospective review was conducted of patients with adult spinal deformity who underwent fusion of at least the lumbar spine (UIV > L1 to pelvis) during 2013-2018. Demographic and radiographic data were collected. The sample was stratified into 3 groups: training (70%), validation (15%) and performance testing (15%). Using a deep learning algorithm, a neural network model was trained to select between upper thoracic (T1-T6) and lower thoracic (T7-T12) UIV. Parameters used in the deep learning algorithm included demographics, coronal and sagittal preoperative alignment, and postoperative pelvic incidence-lumbar lordosis mismatch. The study included 143 patients (mean age 63.3 ± 10.6 years, 81.8% women) with moderate to severe deformity (maximum Cobb angle: 43° ± 22°; T1 pelvic angle: 27° ± 14°; pelvic incidence-lumbar lordosis mismatch: 22° ± 21°). Patients underwent a significant change in lumbar alignment (Δpelvic incidence-lumbar lordosis mismatch: 21° ± 16°, P < 0.001); 35.0% had UIV in the upper thoracic region, and 65.0% had UIV in the lower thoracic region. At 1 year, revision rate was 11.9%, and rate of radiographic proximal junctional kyphosis was 29.4%. Neural network comprised 8 inputs, 10 hidden neurons, and 1 output (upper thoracic or lower thoracic). After training, results demonstrated an accuracy of 81.0%, precision of 87.5%, and recall of 87.5% on testing. An artificial neural network successfully mimicked 2 lead surgeons' decision making in the selection of UIV for adult spinal deformity correction. Future models integrating surgical outcomes should be developed.

Structured Feedback Enhances Compliance with Operating Room Debriefs

BackgroundSurgical debriefs help reduce preventable errors in the operating room (OR) leading to patient injury. However, compliance with debriefs remains poor. The objective of this study was to evaluate the role of structured feedback to surgeons in improving compliance with and quality of surgical debriefs. Materials and methodsSurgical cases at an 875-bed urban teaching hospital from January-June 2019 were audited via audio/video recording to evaluate debrief performance. Debriefs were evaluated for clinical completeness and teamwork quality via two structured forms. Surgeons received an evaluation of their debrief performance at two time points during the study period (February and April). Univariate and mixed-effects regression analyses were used to assess changes in debrief compliance and quality over time. ResultsA total of 878 surgical cases performed by 61 surgeons were reviewed: 198 (22.6%) cases during Period 1 (P1), 371 (42.3%) P2, and 309 (35.1%) P3. The rate at which a debrief occurred was 62.1% in P1, 73.0% in P2, and 82.2% in P3 (P < 0.001). Debriefs were 1.96 (95% CI 1.31-2.95, P = 0.001) times more likely to be completed during P2 and 3.21 (95% CI 2.07-5.04, P < 0.001) times more likely during P3 compared to P1. The percent of debriefs initiated by the lead surgeon increased from 59.8% in P1, to 80.0% in P2, to 81.5% in P3 (P < 0.001). ConclusionsProviding structured feedback to surgeons on their debrief performance was associated with improvements in compliance and completeness with debriefing protocols, OR teamwork and communication, and leadership and accountability from the lead surgeons.

Exploring the use of high and low demand simulation for human performance assessment during multiorgan retrieval with the joint scrub practitioner

IntroductionThe National Organ Retrieval Service (NORS) 2015 review recommended a Joint Scrub Practitioner for abdominal and cardiac teams during combined organ retrieval. To evaluate the feasibility of this role, and...

Preclinical evaluation of the versius surgical system, a new robot-assisted surgical device for use in minimal access general and colorectal procedures

ObjectiveTo evaluate the utility of a new robot-assisted surgical system (the Versius Surgical System, CMR Surgical, Cambridge, UK) for use in minimal access general and colorectal surgery, in a preclinical setting.Summary background dataRobot-assisted laparoscopy has been developed to overcome some of the important limitations of conventional laparoscopy. The new system is designed to assist surgeons in performing minimal access surgery and overcome some of the challenges associated with currently available surgical robots.MethodsCadaveric sessions were conducted to evaluate the ability of the system to provide adequate surgical access and reach required to complete a range of general and colorectal procedures. Port and bedside unit positions were recorded, and surgical access and reach were evaluated by the lead surgeon using a visual analogue scale. A live animal (porcine) model was used to assess the surgical device’s safety in performing cholecystectomy or small bowel enterotomy.ResultsNine types of procedure were performed in cadavers by nine lead surgeons; 35/38 procedures were completed successfully. The positioning of ports and bedside units reflected the lead surgeons’ preferred laparoscopic set-up and enabled good surgical access and reach. Cholecystectomy (n = 6) and small bowel enterotomy (n = 5) procedures performed in pigs were all completed successfully by two surgeons. There were no device-related intra-operative complications.ConclusionsThis preclinical study of a new robot-assisted surgical system for minimal access general and colorectal surgery demonstrated the safety and effectiveness of the system in cadaver and porcine models. Further studies are required to assess its clinical utility.

Using Fully-Immersive Simulation Training with Structured Debrief to Improve Nontechnical Skills in Emergency Endovascular Surgery

Assess whether fully-immersive simulation training with structured debriefing of a standardized emergency thoracic endovascular aortic repair (TEVAR) scenario improves team-work performance of the lead surgeon. Secondary aims: assess whether technical skills (TS) and radiation safety behaviors (RSB) improved concurrently. Pre-post study. UK-based training days. General and vascular surgical trainees (n = 16). Fully-immersive simulation training with structured debriefing of a standardized emergency TEVAR scenario. Following standardized emergency TEVAR technical training, trainees led 2 standardized fully-immersive endovascular surgery simulations, with scripted support from a passive surgical team. A non-TS (NTS) structured debrief was delivered following simulations. NTS were assessed using the validated observational teamwork assessment for surgery tool post hoc using video recordings of simulations. TS were assessed through time taken to complete each step of the procedure, as defined during technical training. RSB were assessed through checking for presence of pre-defined actions and the length of time fluoroscopy was used during each simulation. Total observational teamwork assessment for surgery scores improved following structured debrief (p = 0.005, median 52.55/90 vs 73.0/90), alongside all constituent domains - communication (p < 0.001, median 11.7/20 vs 16.6/20), coordination (p < 0.001, median 8.6/15 vs 13.4/15), cooperation (p < 0.001, median 13.15/20 vs 16.35/20), leadership (p < 0.001, median 8.70/15 vs 11.30/15) and monitoring (p < 0.001, median 9.85/20 vs 14.85/20). TS improved; time to complete 12 of 13 procedural steps improved (p < 0.027). Fluoroscopy time (seconds) decreased (p = 0.339, 543.6 vs 495.5), frequency lead surgeons checked the team were wearing leads increased (p = 0.125, 3 vs 7) and asked the team to step back before screening increased (p = 0.003, frequency team asked to step back/total angiography runs before = 2/36 vs after = 14/44). fully-immersive endovascular simulation with structured debrief is a robust tool to improve NTS and TS. Incorporation into surgical training may reduce operating theatres errors, increase efficiency, and improve RSB. However effective translation into the clinical workplace must be demonstrated to see these benefits.

Preclinical Evaluation of the Versius Surgical System, a New Robot-assisted Surgical Device for Use in Minimal Access Renal and Prostate Surgery

BackgroundMinimal access surgery (MAS) is well-established in urological surgery. However, MAS is technically demanding and associated with a prolonged learning curve. Robot-assisted laparoscopy has made progress in overcoming these challenges. ObjectiveThe aim of this study was to evaluate the feasibility of a new robot-assisted surgical system (the Versius Surgical System; CMR Surgical, Cambridge, UK) for renal and prostate procedures in a preclinical setting, at the IDEAL-D phase 0. Design, setting, and participantsCadaveric sessions were conducted to evaluate the ability of the system to complete all surgical steps required for a radical nephrectomy, prostatectomy, and pelvic lymph node dissection. A live animal (porcine) model was also used to assess the surgical device in performing radical nephrectomy safely and effectively. Procedures were performed by experienced renal and prostate surgeons, supported by a full operating room team. Outcome measurements and statistical analysisSurgical access and reach were evaluated by the lead surgeon using a visual analogue scale. The precise surgical steps conducted to make the assessment that the procedures could be completed fully were recorded, as well as instruments used (including manual laparoscopic instruments) and endoscope angle. Results and limitationsIn total, all 24 procedures were completed successfully in cadavers by eight different lead surgeons. Positioning of the ports and bedside units reflected the lead surgeon’s preferred laparoscopic set-up and enabled good surgical access and reach, as quantified by a median visual analogue score of ≥6.5. Radical nephrectomies performed in pigs were all completed successfully, with no device- or non–device-related intraoperative complications recorded. Testing in human cadavers and pig models balances the bias introduced by each model; however, it is impossible to completely replicate the experience and performance of the robot for surgery in live humans. ConclusionsThis is the first preclinical assessment of the Versius Surgical System for renal and prostate procedures. The safety and effectiveness of the system have been demonstrated and warrant progressive assessment in a clinical setting utilising the IDEAL-D framework. Patient summaryIn this report, we looked at the usability of a new robot-assisted surgical device for renal and prostate surgery by testing the system in cadavers and pigs. We found that a number of different surgeons and operating team personnel were able to use the system to successfully complete the procedures under evaluation. We conclude that the system is ready to be tested in live human studies.

Louisa on the Front Lines: Louisa May Alcott in the Civil War

Louisa on the Front Lines: Louisa May Alcott in the Civil War

Effect of a Knowledge-Translation Intervention on Breast Surgeons' Oncofertility Attitudes and Practices.

The breast surgeon, generally the first oncology specialist consulted, is ideally suited to offer fertility preservation (FP) referral to young women with breast cancer (YWBC). In the authors' 2015 survey of 84 surgeons participating in the pan-Canadian RUBY study of YWBC, oncofertility knowledge and rates of FP referral were suboptimal. The authors designed an oncofertility knowledge-translation intervention for surgeons. A customized oncofertility toolbox was created including a seminar/webinar, an option grid, a three-question FP survey sent upon registration of each RUBY patient, and a management checklist. In 2018, the 28 site lead surgeons were re-invited to participate in a follow-up telephone interview, and 85 non-site lead surgeons were invited to complete a follow-up online questionnaire. A total of 27 site lead surgeons consented to be re-interviewed. After the intervention, 85% indicated that they "routinely" initiated a fertility discussion compared with 54% at baseline (p < 0.005), with 56% stating that the toolbox had been helpful for making positive changes in their practice regarding oncofertility, and 44% stating that they found it easier to initiate a fertility discussion. Among the 55 non-site lead surgeons who completed the questionnaire, a significant improvement in oncofertility knowledge was found. The percentage reporting "rarely" or "never" discussing FP options decreased from 41 to 14% (p < 0.005), and 84% stated that they referred patients who had not completed their families and were at risk for infertility to FP consultation compared with 32% before the intervention (p < 0.001). A multi-pronged but simple knowledge-translation intervention improved the attitudes, knowledge, and FP practice of Canadian breast surgeons.

Use of an Assistant Surgeon Does not Mitigate the Effect of Lead Surgeon Volume on Outcomes Following Open Repair of Intact Abdominal Aortic Aneurysms

While higher lead surgeon volume has been associated with lower mortality following open abdominal aortic aneurysm (AAA) repair, little is known about the impact of using an attending surgeon as assistant surgeon. The aim of this study was to determine whether the presence of an assistant surgeon, particularly a high volume assistant, mitigates the relationship between lead surgeon volume and outcomes. All Medicare beneficiaries who underwent intact, open AAA repair between 2003 and 2008 were evaluated and nested regression models were constructed to evaluate the relationship between surgeon and assistant volume and peri-operative mortality, adjusting for comorbid conditions and hospital volume. In total 28,590 repairs were studied, of which 19,284 (67.5%) were performed by a single surgeon and 9306 (32.5%) included an assistant surgeon. Of cases with an assistant, 12.3% included a high volume assistant surgeon. Lower volume surgeons more frequently used an assistant (lead surgeon Q1 volume: 40%; Q2: 36%; Q3: 34%; Q4: 29%; Q5: 27% [p < .01]). In cases with no assistant, adjusted peri-operative mortality varied monotonically with surgeon volume (Q1: 4.7%; Q2: 4.4%; Q3: 4.1%; Q4: 3.3%; Q5: 3.2%). However, the use of a high or a low volume assistant surgeon, compared with no attending surgeon as assistant, was not associated with lower peri-operative mortality in any lead surgeon volume quintile, even among those operations performed by the lowest volume lead surgeons. Employing an assistant surgeon does not improve outcomes amongst any quintile of volume of the lead surgeon. As surgeons perform fewer open AAA repairs in the modern era, these data imply that even the help of a high volume assistant surgeon may not mitigate the detrimental effect of a lower volume surgeon.

Fully laparoscopic left hepatectomy – a technical reference proposed for standard practice compared to the open approach: a retrospective propensity score model

BackgroundLaparoscopic left hemihepatectomy (LLH) may be an alternative to open (OLH). There are several original variations in the technical aspects of LLH, and no accepted standard. The aim of this study is to assess the safety and effectiveness of the technique developed at Henri Mondor Hospital since 1996. MethodsThe technique of LLH was conceived for safety and training of two mature generations of lead surgeons. The technique includes full laparoscopy, ventral approach to the common trunk, extrahepatic pedicle dissection, CUSA® parenchymal transection, division of the left hilar plate laterally to the Arantius ligament, and ventral transection of the left hepatic vein. The outcomes of LLH and OLH were compared. Perioperative analysis included intra- and postoperative, and histology variables. Propensity Score Matching was undertaken of background covariates including age, ASA, BMI, fibrosis, steatosis, tumour size, and specimen weight. Results17 LLH and 51 OLH were performed from 1996 to 2014 with perioperative mortality rates of 0% and 6%, respectively. In the LLH group, two patients underwent conversion to open surgery. Propensity matching selected 10 LLH/OLH pairs. The LLH group had a higher proportion of procedures for benign disease. LLH was associated with longer operating time and less blood loss. Perioperative complications occurred in 30% (LLH) and 10% (OLH) (p = 1). Mortality and ITU stay were similar. ConclusionThis technique is recommended as a possible technical reference for standard LLH.

Humanitarian Cardiology and Cardiac Surgery in Sub-Saharan Africa: Can We Reshape the Model?

In recent decades, humanitarian cardiology and cardiac surgery have shifted toward sending short-term surgical and catheter missions to treat patients. Although this model has been shown to be effective in bringing cardiovascular care to the patients' environment, its effectiveness in creating sustainable service is questioned. This study reports the barriers to contribution of missions to effective skill transfer and possible improvements needed in the future, from the perspective of both the local and overseas teams. We reviewed the mission-based activities in the Children's Heart Fund Cardiac Center in the past six years. We distributed questionnaires to the local surgeons and the lead surgeons of the overseas teams. Twenty-six missions visited the center 57 times. There were 371 operating days and 605 surgical procedures. Of the procedures performed, 498 were open-heart surgeries. Of the operations, 360 were congenital cases and 204 were rheumatic. Six local surgeons and 18 overseas surgeons responded. Both groups agree the current model of collaboration is not optimal for effective skill transfer. The local surgeons suggested deeper involvement of the universities, governmental institutions, defined training goals and time frame, and communication among the overseas teams themselves as remedies in the future. Majority of the overseas surgeons agree that networking and regular communication among the missions themselves are needed. Some reflected that it would be convenient if the local surgeons are trained by one or two frequently visiting surgeons in their early years and later exposed to multiple teams if needed. The current model of collaboration has brought cardiac care to patients having cardiac diseases. However, the model appears to be suboptimal for skill transfer. The model needs to be reshaped to achieve this complex goal.

Oncofertility Knowledge, Attitudes, and Practices of Canadian Breast Surgeons.

Guidelines recommend that oncologists discuss treatment-related fertility issues with young cancer patients as early as possible after diagnosis and, if appropriate, expedite referral for fertility preservation (FP). This study sought to determine the attitudes and practices of Canadian breast surgeons regarding fertility issues, as well as barriers to and facilitators of fertility discussion and referrals. Semistructured telephone interviews were conducted with 28 site lead surgeons (SLSs) at 28 (97 %) of 29 centers (25 % cancer centers, 64 % teaching hospitals) across Canada participating in RUBY, a pan-Canadian research program for young women with breast cancer. In addition, 56 (65 %) of 86 of their surgical colleagues (non-site lead surgeons [NSLSs]) completed an online survey of their oncofertility knowledge, attitudes, and practices. Of the 28 SLSs (43 % male, 36 % in practice <10 years), 46 % had inadequate oncofertility knowledge, 25 % discussed fertility only if mentioned by the patient, 21 % believed fertility discussion and referral were the mandate of the medical oncologist, and 45 % did not know of an FP center in their area. More than 80 % of the NSLSs (54 % male, 30 % in practice <10 years) were unfamiliar with oocyte or embryo cryopreservation; 36 % never or rarely discussed fertility issues; and 51 % thought referral to a fertility specialist was not their responsibility. Oncofertility knowledge was low among the SLSs, especially the NSLSs, and barriers to referral were identified. An oncofertility knowledge translation intervention specifically for breast surgeons is being developed to increase surgeon knowledge and awareness of oncofertility issues and referral.

Abstract P6-12-01: Attitudes and practice of breast surgeons towards referring young women with breast cancer (YWBC) for fertility preservation (FP)

Abstract Background: Despite ASCO guidelines (2006, 2013) recommending that young cancer patients be offered referral for FP as soon as possible after diagnosis, the literature consistently shows suboptimal referral rates for YWBC. Surgeons are in a unique position to initiate early FP referral. Surgeon &amp; Patient Oncofertility Knowledge Enhancement (SPOKE) is one of 5 components of the pan-Canadian RUBY research program for YWBC. SPOKE aims to improve breast surgeon FP knowledge and referral rates. The lead surgeon from each of the RUBY sites was previously interviewed about FP. The goal of the current survey was to assess the baseline oncofertility attitudes and practice of the non-lead breast surgeons at those sites. Methods: An online survey taking approximately 10 minutes to complete was developed specifically for this study. In February 2015, an email invitation with a hyperlink to the anonymous survey was sent to all 86 surgeons identified by the 23 lead surgeons. Repeated reminders were sent by the research assistant over 3 months and a final request was sent by the PI. Participants received a $25 gift certificate. Results: A total of 55/86 (64%) surgeons with an average of 15 years' surgical practice completed the survey. 53% were male, 56% were under age 50, and 93% worked at a cancer centre or university-affiliated hospital. Thirty respondents (55%) indicated that more than half of their practice was breast cancer. Twenty (36%) never or rarely initiated a fertility discussion, and 23 (42%) never or rarely discussed FP options with their YWBC. Twenty-two respondents (40%) stated it was the duty of the medical oncology rather than the surgical team to initiate fertility discussions. Only a minority were quite or very familiar with egg freezing (n=10, 19%) and embryo freezing (n=11, 20%), while only 7 (13%) felt comfortable discussing egg or embryo freezing with their patients. Twenty-four (44%) did not know a FP centre in their area to which they could refer. Compared to surgeons who assumed responsibility for fertility discussion, surgeons who did not think FP referral was their clinical responsibility were less familiar with egg freezing (21% vs. 63%, p&amp;lt;.001) and embryo freezing (32% vs. 73%, p&amp;lt;.01), and were less likely to know where to send FP referrals (31% vs. 85%, p&amp;lt;.05). The most common patient factors that surgeons stated would deter them from FP referral were: poor prognosis, need to start chemotherapy urgently, and already having children. A quarter of surgeons said they would be less likely to refer a highly anxious YWBC for FP. Conclusions: Many Canadian breast surgeons are unaware of the importance of early FP referral and nearly half surveyed did not consider FP referral to be their mandate. A majority of these surgeons lack sufficient oncofertility knowledge to feel comfortable mentioning FP options to their patients, and have not created a protocol for FP referral by the surgical team. In the next phases of the SPOKE study, a knowledge translation intervention will be developed and its effectiveness tested. Support: Canadian Breast Cancer Foundation &amp; Canadian Institute of Health Research (OBW139590). Citation Format: Warner E, Yee S, Glass K, Kennedy E, Foong S, Seminsky M. Attitudes and practice of breast surgeons towards referring young women with breast cancer (YWBC) for fertility preservation (FP). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-12-01.