Master Surgeon Research Articles

788. LAPAROSCOPIC TOUPET FUNDOPLICATION - PERSONAL EXPERIENCE 174 CASES REPORT

Abstract Background Gastroesophageal Reflux Disease (GERD) is one of the most important disorders of the gastrointestinal system, affecting 20% t o 40% of the population of the United States of America, and 12% on the world. There are several surgical techniques for treating this disease, including the Toupet Fundoplication technique, which reduce the postoperative complications, like dysphagia, Gas Bloating Syndrome and incapacity to belch. Methods Prospective cohort study with 174 patients in two hospitals, one public and the other private, in the city of Natal, Brazil. All patients were evaluated postoperative as the following: 1) first week after the surgery were interviewed by the master surgeon; 2) fifty days after surgery were submitted to a Barium Swallow; 3) three months after the surgery the endoscopy was performed. The follow-up was carried out in relation to the symptom of postoperative dysphagia, ability to belch, feeling of fullness and gastroesophageal reflux. Results A total of 174 patients were observed, who were submitted for the Toupet Fundoplication procedure. Of this total, 145 patients were followed-up. 143 patients had improvement of symptoms related to esophageal disease and are clinically satisfied. One patients had recurrence of reflux symptoms. One patient had Gas Bloating Syndrome. Conclusion Toupet Fundoplication was a standard procedure in the study and achieved good results in 98,62% of the cases followed during follow-up of GERD control and relief symptoms with a minimal rate of adverse effects in the postoperative period.

792. EVALUATION OF EXTENSIVE MYOTOMY ASSOCIATED WITH DOR-MODIFIED ANTERIOR FUNDOPLICATION (PINOTTI) FOR SHORT- AND LONG-TERM TREATMENT OF ACHALASIA: A COHORT STUDY

Abstract Introduction Achalasia is the main esophageal motility disorder and has a significant negative impact on the patient's quality of life. The management of achalasia primarily aims to reduce LES pressure. Surgical treatment involves a Heller myotomy, combined with a fundoplication to prevent reflux. Method Prospective cohort study with 79 patients in two hospitals, one public and one private, in the city of Natal, Brazil. To evaluate the effectiveness of the surgical technique developed with the intention of treating achalasia, a long myotomy associated with the modified Dor anterior fundoplication (Pinotti). All patients were evaluated postoperatively as follows: 1) first week after surgery they were interviewed by the master surgeon; 2) thirty days after surgery they were interviewed regarding symptoms of achalasia in the postoperative period. Results Seventy nine (79) patients were submitted for a long myotomy procedure associated with modified Dor anterior fundoplication (Pinotti). Seventy nine (79) patients were followed up. Although, seventy three (73) patients had improvement in symptoms related to achalasia and are clinically satisfied. Six (6) patients had recurrence of achalasia symptoms, such as dysphagia. Conclusion The long myotomy associated with the modified Dor anterior fundoplication (Pinotti) was the standard procedure in the study and obtained good results in 89,83% of the cases followed during the control of achalasia symptoms with a minimum rate of adverse effects in the postoperative period

R. Randal Bollinger, M.D., Ph.D., Master Surgeon.

R. Randal Bollinger, M.D., Ph.D., Master Surgeon.

A comparative study in learning curves of laparoscopic lateral suspension vs. laparoscopic sacrocolpopexy: preliminary results.

Determination of the learning curve of new techniques is essential to improve safety and efficiency. Limited information is available regarding learning curves of different techniques in laparoscopic pelvic floor surgery. The aim of this study was to compare the learning curve of two operative techniques, laparoscopic lateral suspension (LLS) and laparoscopic sacrocolpopexy (LSC). We conducted a prospective study to assess the learning curve of LLS and LSC by implementing a structured urogynecologic surgical training program with the use of pelvic trainers for our urogynecology fellow. The fellow was an experienced urogynecologic surgeon, but was laparoscopic suturing and dissection naive at the beginning of the study. She was required to assist in 20 laparoscopic urogynecologic surgeries and undertake laparoscopic suturing and knot tying training with mesh positioning on a laparoscopic trainer for 4 h/week during the trial period. After the completion of this structured training program, the fellow performed LLS and LSC under the supervision of an experienced subspecialist as the primary surgeon. Linear regression analysis was used to compare the data of LLS and LSC learning curves. Subjective pre- and post-operative evaluation of pelvic organ prolapse (POP) and pelvic floor disorders was undertaken preoperatively and 12 months postoperatively using the PFDI-20-Quality of Life validated questionnaire. Follow-up was scheduled 12 months after the surgery and performed by a skilled urogynecologist. Objective cure was defined as Pelvic Organ Prolapse-Qualification (POP-Q) stage <II in any compartment. The mean operative times of laparoscopic sacrocolpopexy and lateral suspension were 168.26 and 160.33 min, respectively. According to linear regression analysis after 43 procedures, the learning curve for laparoscopic lateral suspension was shorter than for laparoscopic sacrocolpopexy (OPTime 134.69 min). In both groups, there was a significant reduction in bothersome POP symptoms (p ≤ 0.005). Bladder injuries in two cases and lumbar pain in one case were recorded during the study. Overall objective success at 12 months was 90.7% for LSC and 89.1% for LLS. Laparoscopic lateral suspension could be an alternative to laparoscopic sacrocolpopexy in the treatment of POP with its good objective and subjective outcomes. Lateral suspension has a shorter learning curve, and it is technically less demanding than LSC. Procedure-dedicated training can accelerate the move from a novice to a master laparoscopic surgeon.

422. LAPAROSCOPIC TOUPET FUNDOPLICATION EVALUATION FOR GASTROESOPHAGEAL REFLUX DISEASE SHORT AND LONG-THERM FOLLOW-UP: A COHORT STUDY

Abstract Background Gastroesophageal Reflux Disease (GERD) is one of the most important disorders of the gastrointestinal system, affecting 20% to 40% of the population of the United States of America. There are several surgical techniques for treating this disease, including the Toupet Fundoplication technique, which reduce the postoperative complications, like dysphagia, Gas Bloating Syndrome and incapacity to belch. Methods Prospective cohort study with 138 patients in two hospitals, one public and the other private, in the city of Natal, Brazil. All patients were evaluated postoperative as the following: 1) first week after the surgery were interviewed by the master surgeon; 2) fifty days after surgery were submitted to a Barium Swallow; 3) three months after the surgery the endoscopy was performed. The follow-up was carried out in relation to the symptom of postoperative dysphagia, ability to belch, feeling of fullness and gastroesophageal reflux. Results A total of 140 patients were observed, who were admitted for the Toupet Fundoplication procedure. Of this total, 74 patients were followed-up. 68 patients had improvement of symptoms related to esophageal disease and are clinically satisfied. 6 patients had recurrence of reflux symptoms. One patient still doesn’t belch. One patient had Gas Bloating Syndrome. Conclusion Toupet Fundoplication was a standard procedure in the study and achieved good results in 91,89% of the cases followed during follow-up of GERD control and relief symptoms with a minimal rate of adverse effects in the postoperative period.

Denton A. Cooley: Master surgeon and educator

Denton A. Cooley: Master surgeon and educator

Objective assessment for open surgical suturing training by finger tracking can discriminate novices from experts

ABSTRACT It is difficult, time consuming and expensive to assess manual skills in open surgery. The aim of this study is to investigate the construct validity of a low-cost, easily accessible tracking technique for basic open suturing tasks. Medical master students, surgical residents, and surgeons at the Radboud University Medical Center were recruited between September 2020 until September 2021. The participants were divided, according to experience, in a novice group (≤10 sutures performed) and an expert group (>50 sutures performed). For objective tracking, a tablet with SurgTrac software was used, which tracked a blue and a red tag placed on respectively their left and right index finger. The participants executed four basic tasks on a suturing model: 1) knot tying by hand, 2) transcutaneous suturing with an instrument knot, 3) ‘Donati’ (vertical mattress suture) with an instrument knot and 4) continuous intracutaneous suturing without a knot. In total 76 participants were included: 57 novices and 19 experts. All four tasks showed significant differences between the novice group and expert group for the parameters time (p<0.001), distance (p<0.001 for Task 1, 2 and 3 and p=0.034 for Task 4) and smoothness (p<0.001). Additionally, Task 3 showed a significant difference for the parameter handedness (p=0.006) and Task 4 for speed (p=0.033). Tracking index finger movements using SurgTrac software on a tablet while executing basic open suturing skills on a simulator shows excellent construct validity for time, distance and motion smoothness in all four suturing tasks.

Mastering the Craft: Super Star Athletes and Master Surgeons: Are We the Same? Do We Differ?

Mastering the Craft: Super Star Athletes and Master Surgeons: Are We the Same? Do We Differ?

In Memoriam: Randall B. Griepp (1940-2022): Master Surgeon, Innovator, Scientist, Teacher, and Sailor

Dr Randall B.Griepp's career spanned the founding age of cardiovascular and thoracic aortic surgery, the era he called "the golden age of cardiac surgery." He made groundbreaking contributions in cardiac transplantation while at Stanford and in the surgical technique and the methods of cerebral and spinal cord protection for thoracic and thoracoabdominal aortic surgery throughout his years as chairman of cardiothoracic surgery at The Mount Sinai Medical Center in New York. His commitment to honesty and his personal ethic and stature served as a role model for a generation of trainees, many of whom went on to leadership roles in cardiovascular surgery.

Distortions in the Balance Between Teaching and Efficiency in the Operating Room

IntroductionThe balance between teaching and operative efficiency (i.e., continuing operative case progression) is difficult for even the most experienced master surgeon educators. The purpose of this study was to explore influencing factors behind attending surgeons’ decisions to break the balance between operative efficiency and teaching in the operating room. MethodsSemistructured interviews were conducted with surgeons across the United States via Web-based video conferencing. The interviews were audio-recorded and transcribed. Qualitative analysis using the framework method was utilized, and emergent themes were identified. ResultsTwenty-three attending surgeons from 8 academic institutions and 11 surgical specialties completed interviews (14 men and 9 women). Attending surgeons consider a variety of factors associated with their dual roles (surgeon versus teacher) when balancing operative efficiency and providing appropriate independence for residents with oversight to promote autonomy. These were divided into surgeon-role-related factors (patient safety, financial factors, scheduling factors, preservation of faculty reputation for efficiency, and mode of operation) as well as teacher-role-related factors (preparation, level, and technical skill of the resident). These factors then informed attending surgeons’ determinations about how the case was progressing, which prompted them to intervene and reduce resident autonomy or allow the resident to continue. ConclusionsSurgeons consider numerous factors when deciding how to balance resident teaching and autonomy while preserving operative efficiency. These findings provide helpful insights for surgical departments to consider inclusion in faculty-development programs, resident education, and systematic improvements.

A master surgical educator: the “intrinsic” factor of Dr. Paul Greig

In the spring of 2019, one of the giants of hepatobiliary, pancreatic and transplant surgery retired. Dr. Paul Greig, a master surgeon, outstanding educator, and wonderful human being decided that the time of putting his knife down had finally come. As with many great musicians, he knew exactly when the right moment to stop his music arrived. His retirement, however, should not be in silence. His amazing legacy is too loud for that, even louder than his beloved rock and roll music.

Early weight-bearing constructs in the lower extremity

In early 2020, in the editorial “A call to arms: it's time to bear weight,” Trompeter[1] stated: “as we travel down the limb, we see an increased reluctance on the part of the treating surgeon to allow the patient to bear weight postoperatively.” While early weight-bearing in postoperative hip fracture constructs is well established, fractures distal to the hip are less likely to be allowed full mobilization, even in the frail elderly. A steadily increasing stream of literature, from the ankle up, shows potential advantages in immediate weight-bearing in the lower extremity with few, if any, ill effects.[2–5] While the literature itself is not always Level 1 or methodologically robust, surgeons must be aware of this option as they deal with an onslaught of fragility fractures in the lower extremity.[6] In the last 10 years of Orthopaedic Trauma Association material, early weight-bearing studies have been published, but the topic has never had its own focus in a supplement. We believe it is important for the Orthopaedic Trauma Association to give this subject focused traction, so that community and other surgeons feel comfortable initiating these changes after learning from the experiences of master surgeons who are early adopters and pioneers of new constructs and techniques in this arena. Early mobility and weight-bearing is extremely important for decreasing medical complications, morbidity, and mortality in our patients, particularly in the elderly. The aims of this supplement include a combination of thorough literature reviews, case series replete with examples of constructs such as the nail-plate for the distal femur, and technique tips to increase the comfort of the treating surgeon in allowing early weight-bearing. Special attention is paid to the distal femur, as a fragility fracture with similar morbidity as hip fractures, but the supplement also includes the proximal tibia/plateau, distal tibia, and ankle.

A comparative study of mass closure versus layered closure in midline laparotomy incisions

Background: The ideal method of abdominal wound closure remains to be discovered. It should be technically so simple that the results are as good in the hands of a trainee as in those of the master surgeon. The best abdominal closure technique should be fast, easy, and cost effective while preventing both early and late complications. Present study is undertaken to compare the two methods (Mass closure and Layered closure) of laparotomy wound closure in relation to post-operative complications, time for wound closure and cost effectiveness in both groups and also to decide the most effective method among the two procedures. Methods: This prospective comparative study was conducted in department of surgery at Narayana medical college and hospital Nellore from December 2019 to December 2021. On admission, patients suspected of having intraabdominal pathology, a thorough clinical and general assessment was done. Necessary radiological and biochemical investigations were done to support the diagnosis. After confirmation of diagnosis patients were subjected for exploratory laparotomy. The laparotomy wound was closed with either by Mass closure or Layered closure technique. Patients were followed up for 6 months in post-operative period for detection of late complications. Results: Total 30 patients of were studied. Majority of patients were in 61 to 65 age group. Male outnumbered the females. Incidence of early complications like seroma, wound infection is more in layered closure group as compared to mass closure. Mean wound closure time is more in layered closure group. Mass closure technique is more cost effective than layered closure group. Conclusions: Mass closure technique is less time consuming, more cost effective and safe for closure of midline laparotomy incisions.

Spontaneous Human Combustion and Claude-Nicolas Le Cat’s Hunt for Fame

This article discusses eighteenth-century ideas about spontaneous human combustion: the idea that the human body—but especially the bodies of idle and liquor-drinking women—could burst into flames with no external source. It focuses particularly on the ideas and career strategies of the author of the most well-known text on this phenomenon, the master surgeon, medical popularizer, and academician Claude-Nicolas Le Cat. Le Cat was deeply involved in efforts to popularize medicine and science and was, at the same time, a deeply ambitious individual anxious to elevate himself to ever-greater prominence. To accomplish these aims, he needed to find ways to attract attention for himself and his ideas while maintaining his image as a serious man of science and not a charlatan. He and other medical authors worked in a kind of feedback loop, in which their pessimistic views about health, modernity, and degeneration led them to imagine ambitious reform projects that would improve health by transforming society itself. To do so, they needed to grab the public’s attention, which encouraged them to state their fears and concerns in sensational and alarmist terms. The article contributes to the history of medicine and science and explores larger themes of celebrity, expertise, and publicity. Engaging the public, even as an expert, neither was nor is a purely rational exercise, and studying Le Cat’s public relations strategies as well as his ideas makes clear how fraught this endeavor could be.

72nd Southwestern Surgical Congress Claude H. Organ, Jr. memorial lecture: Rise ofacutecareroboticsurgery forcommonemergencygeneralsurgeryconditions

Dr. Claude Organ rose above poverty, racism, and untold insurmountable odds to become a masterful surgeon and revered leader in numerous academic and professional circles. But it's his impact on surgical education and his philosophy to “teach, give back, and keep advancing” that inspired this lecture. Acute care robotic surgery (ACRS) utilizes the strengths of robotic assisted laparoscopic surgery (RALS) for a high-volume population of emergency general surgery (EGS) patients. The future benefits of ACRS may include improvements in resident training, patient safety, and outcomes. General surgery residencies that have a robust ACRS program are likely to be more competitive than those without.

Insights and Practice Habits from International Master Surgeons Regarding Pre- and Intra-operative Risk Assessment of Pancreatic Fistula During Pancreatoduodenectomy

Casciani, Fabio MD; Bassi, Claudio MD, FRCS, FACS; Vollmer, Charles M. Jr. MD, FACS Author Information

Training in cardiothoracic surgery: Another victim of COVID-19 pandemic.

Training in cardiothoracic surgery: Another victim of COVID-19 pandemic.

Decision-making from international master surgeons regarding operative techniques for pancreatic-enteric anastomotic reconstruction during pancreatoduodenectomy

Purpose: To evaluate decision-making processes and practice habits from international experts regarding pancreatico-enteric anastomotic creation during pancreatoduodenectomy (PD). In fact, despite ample retrospective studies and RCTs, no consensus exists concerning optimal techniques for pancreatico-enteric anastomotic reconstruction. Method: A questionnaire was completed by 60 select international pancreatic surgery experts from 22 countries (median career pancreatectomy/PD volumes: 1200/705). Their thought-processes and practice regarding pancreatico-enteric anastomotic technique were explored through checkbox questions, free-text responses, and clinical vignettes. Results: Technical considerations and approaches employed during PD by these master surgeons are displayed in Figure. Retrocolic trans-mesenteric orientation of the pancreatic-biliary limb is by far the preferred approach (78%). Duct-to-mucosa (DTM) pancreatico-jejunostomy (PJ) is the most frequently adopted technique (78%), through either the Cattel-Warren (45%) or Blumgart approach (33%). Conversely, both dunking PJ and pancreato-gastrostomy (PG) are rarely employed (<5%). Notably, all surgeons employ some tools to improve sewing precision, such as ocular loupes (45%), temporary internal stents (43%) or headlights (37%). For both PJ and PG, the majority employ 3-0, non-absorbable sutures for the outer layer, and finer, absorbable, monofilament sutures (6-0, 5-0, 4-0) for the inner layer - particularly for duct-to-mucosa PJ (5-0: 64%). Half of surgeons believe that suture material influences anastomotic healing, whereas only 14% usually adapt their choice based on parenchymal characteristics.When encountering a ≤1mm pancreatic duct, 61% of surgeons would dilate it using a probe and 59% would cut back further and still try a DTM anastomosis, whereas directly performing a dunking PJ or a PG is infrequently applied (≤10%). If this initial approach was unsatisfactory, two-thirds would opt for a dunking/invaginating PJ, 22% would perform PG, and just 3% would apply duct occlusion/completion pancreatectomy. Conclusion: Even at the expert level, approaches to this anastomosis are non-uniform, and their relative effectiveness in yielding optimal outcomes are still unresolved

Newcomers, Migrants, Surgeons: Making Career in the Amsterdam Surgeons’ Guild of the Eighteenth Century

Like many modern organizations, the Amsterdam Surgeons’ Guild recruited its members during the eighteenth century from the ranks of locally born citizens as well as migrants. But how a surgeon’s migration status impacted his chances of being admitted by, and making a career within, the Surgeons’ Guild, remains a mystery. This article analyses enrolment lists of apprentices, journeymen, and master surgeons in order to find out how a surgeon’s birth-place influenced his chances of a career within the Amsterdam Surgeons’ Guild. By looking at the guild’s official stance towards newcomers, and pairing this with the actual career paths of migrants within the Amsterdam Surgeons’ Guild, this article demonstrates that migrants could be retained for the guild if they received their apprenticeship training in Amsterdam. In other words, it was not so much origin, but rather the geography of education and work that shaped careers. These results reveal mechanisms of integration that can be generalised to cases outside the Amsterdam Surgeons’ Guild.

Evaluating the Impact of Surgeon Self-awareness by Comparing Self Versus Peer Ratings of Surgical Skill and Outcomes for Bariatric Surgery.

To evaluate variation in self versus peer-assessments of surgical skill using surgical videos and compare surgeon-specific outcomes with bariatric surgery. Prior studies have demonstrated that surgeons with lower peer-reviewed ratings of surgical skill had higher complication rates after bariatric surgery. This is a retrospective cohort study of 25 surgeons who voluntarily submitted a video of a typical laparoscopic sleeve gastrectomy (SG) between 2015 and 2016. Videos were self and peer-rated using a validated instrument based on a 5-point Likert scale (5= "master surgeon" and 1= "surgeon-in-training"). Risk adjusted 30-day complication rates were compared between surgeons who over-rated and under-rated their skill based on data from 24,186 SG cases and 12,888 gastric bypass (GBP) cases. individual overall self-rating of surgical skill varied between 2.5 and 5. Surgeons in the top quartile for self:peer ratings (n = 6, ratio 1.58) had lower overall mean peer-scores (2.98 vs 3.79, P = 0.0150) than surgeons in the lowest quartile (n = 6, ratio 0.94). Complication rates between top and bottom quartiles were similar after SG, however leak rates were higher with gastric bypass among surgeons who over-rated their skill with SG (0.65 vs 0.27, P = 0.0181). Surgeon experience was similar between comparison groups. Self-perceptions of surgical skill varied widely. Surgeons who over-rated their skill had higher leak rates for more complex procedures. Video assessments can help identify surgeons with poor self-awareness who may benefit from a surgical coaching program.